ECE2018 Guided Posters Adrenal clinical (10 abstracts)
The short synacthen test can be used to predict recovery of hypothalamo-pituitary-adrenal axis function and guide clinical practice
Riccardo Pofi 1, , Chona Feliciano 3 , Emilia Sbardella 2 , Nicola Argese 4 , Conor P Woods 5 , Ashley B Grossman 1 , Bahram Jafar-Mohammadi 1 , Helena Gleeson 3 , Andrea Lenzi 2 , Andrea M Isidori 2 & Jeremy W Tomlinson 1
1Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, UK; 2Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy; 3Centre for Endocrinology, Diabetes and Metabolism, Queen Elizabeth Hospital, Birmingham, UK; 4Department of Endocrinology, S.S. Annunziata Hospital, Taranto, Italy; 5Department of Endocrinology, Naas General Hospital, Kildare and Tallaght Hospital, Dublin, Ireland.
The 250 mg short synacthen test (SST) is the most commonly used tool to assess the integrity of hypothalamic-pituitary-adrenal (HPA) axis. There are many instances when compromise to HPA-axis function is potentially reversible (including the use of suppressive dose of prescribed glucocorticoids), but currently there are no data to guide clinicians as to the frequency of repeat testing or to the likelihood of HPA-axis recovery. We performed an observational, retrospective, analysis of data from 1912 SSTs from 776 patients (335 men, 441 women, mean age 53±18 years) in whom potentially reversible causes of HPA-axis compromise and adrenal insufficiency(AI) were identified. At least two SSTs were performed in each patient, the median duration of follow-up was 250 days (95%CI, 224-272). Irreversible causes (pituitary radiotherapy, Addison’s disease, congenital adrenal hyperplasia, adrenal metastases, bilateral adrenalectomy) were excluded. A separate cohort analysis was performed on patients who had been treated with suppressive dose of glucocorticoids (n=110). SST 30-min cortisol level was the best predictor of HPA-axis recovery in patients with reversible AI not exposed to suppressive doses of glucocorticoids (AUC ROC=0.85). Patients with 30-minute cortisol levels >350 nmol/l had a significantly shorter time to HPA-axis recovery (341 vs. 1580 days, P=4.4×10−10). In this group, 99% of patients recovered HPA-axis within 4-years, contrasting with 34% in those with a 30-min cortisol <350 nmol/l. In the group with a 30-min cortisol <350 nmol/l, a subsequent random cortisol of <200 nmol/l (1-year after the initial SST), identified a population in whom only 11% recovered HPA-axis function. In those patients treated with suppressive dose of glucocorticoids, delta cortisol (30-min – basal) was the best predictor of recovery (AUC ROC =0.77). Delta cortisol >100 nmol/l predicted a shorter estimated median recovery time (262 vs. 974 days, P=7.0×10−6). 4-year recovery rates were also different (95% vs. 67%). Moreover, no patient with a delta cortisol <100 nmol and a subsequent random cortisol <200 nmol/l recovered HPA-axis function within the 4-year duration of the study. Using a SST 30-min cortisol in patients with reversible causes of AI, and a delta cortisol in those exposed to high doses of glucocorticoids, can predict recovery of HPA-axis function. We believe that these data will help to guide the frequency of repeat dynamic testing and provide a unique dataset that will inform both clinicians and patients as to the likelihood of restoration of intact HPA-axis function.
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Endocrine Abstracts
ISSN 1470-3947 (print) | ISSN 1479-6848 (online)
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