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16-September-2008 16:15:12 - stimulation test Location of adrenal glands Latin glandula suprarenalis Gray's subject #277 1278 System Endocrine MeSH Adrenal+Glands Dorlands/Elsevier g_06/12392729 The ACTH stimulation test also called the Cortrosyn aka Cosyntropin or Synacthen test is a medical test performed to assess the functioning of the adrenal glands see photo. Specifically, it is used to diagnose or exclude adrenal insufficiency, Addison's disease and related conditions. It involves the injection of synthetic adrenocorticotropic hormone ACTH and measures the amount of cortisol, and sometimes aldosterone, the adrenals produce in response. Apart from objectivating adrenal insufficiency, it can distinguish whether the cause is adrenal low cortisol production or pituitary low ACTH production.1 In healthy individuals, the cortisol level should double from a value at least in the 20s within 60 minutes. If the cortisol level was a 25 before the stimulation base level, after the stimulation should reach at least 50. This test may cause mild side effects in some individuals. These can include nausea, facial flushing or palpitations a fast or fluttering heart beat which are normal reactions, but disappear in a few hours.2 The ACTH stimulation test is recognized by the medical community as final say in whether or not an individual has a degree of adrenal insufficiency, although this test is primarily used to determine the presence of Addison's disease. If the test does not show Addison's for example, in true Addison's, the stimulation may start at 3 and rise to 4 or 6 rising to 8, a doctor may see the test as showing the adrenal glands are working and don't recognize any degree of adrenal insufficiency between Addison's the worst degree of adrenal insufficiency which can cause death and healthy adrenal function. Secondary adrenal insufficiency if often missed as doctors can see doubling or more from a low base cortisol value with low ACTH being okay or even great, not recognizing this indicates low ACTH production. Contents 1 Method of preparation and administration 2 Interpretation for cortisol stimulation 3 Interpretation of ACTH plasma test in conjunction with cortisol stimulation 4 Interpretation for aldosterone stimulation 5 See also 6 References Method of preparation and administration Preparation Must fast for 12 hours before the test which should be done before 10 am, but as close to 7 am as possible.3 This test shouldn't be given if on glucocorticoids, DHEA, pregnenolone or adrenal extract supplement as these will affect test results. Stress and recently administered radioisotope scans can artificially increase levels and may invalidate test results. Spironolactone, contraceptives, estrogen, androgen and progesterone therapy may also affect both aldosterone and cortisol stimulation test results.4 If aldosterone is to be stimulated, salt and foods significant in sodium must be fasted for 24 hours prior to testing. This allows aldosterone to rise as far as possible. Women must test aldosterone in the first week of their cycle. Administration Blood is drawn to get a starting or base cortisol, plasma ACTH should also be tested and or aldosterone level, next synthetic ACTH Synacthen aka Tetracosactide or Cortrosyn aka Cosyntropin is injected. Approximately 20 mL of heparinized venous blood is collected at 30, 45 and 60 minutes after the synthetic ACTH injection. All blood samples are kept on ice and sent immediately to the laboratory for testing.3 The test must be done for at least 60 minutes. Interpretation for cortisol stimulation Interpretation for primary adrenal insufficiency and Addison's disease The base cortisol level in people with adrenal insufficiency is usually in the mid teens. If the ACTH stimulation test raises cortisol level to 20, so that is not doubling and supports the diagnosis of primary adrenal insufficiency. In Addison's, base cortisol is well below 10 and rises no more than 25 percent. Interpretation for secondary adrenal insufficiency The base cortisol can double, triple, quadruple or more from a low base value. Other examples reported include quintupling 5 stimming to 25 ng/dl, 6 stimming to 30, sextupling 4 stimming to 24, 4.1 stimming to 26.9, 5 stimming to 30, septupling 0.7 stimming to 4.9, decupling 2 stimming to 20, 2.7 stimming to 27.6, tridecupling 1.25 stimming to 16, a factor of 12.8 and quadecupling 1.7 stimming to 24, after 1 1/2 hours reached 27.5 for sexdecupling. These examples illustrate how extreme the ACTH stimulation test result can be in secondary adrenal insufficiency, but most people with secondary only double or triple and usually start with a base cortisol value of at least 10. The base cortisol can be very low because of the bodies lack of natural ACTH. When the synthetic ACTH is given to secondaries, the adrenals go hog wild because they can work, just not getting enough ACTH from the pituitary gland.3 In some instances, a second test performed later can suggest primary adrenal insufficiency cortisol value less than doubled. The diagnosis may be changed from secondary to primary adrenal insufficiency or to include primary adrenal insufficiency. In secondary adrenal insufficiency, if the adrenal glands lack ACTH for enough time, cortisol production can atrophy and fail to rise to a value at least double the base cortisol value. It is proper to continue with the secondary diagnosis. Interpretation of ACTH plasma test in conjunction with cortisol stimulation An ACTH plasma test should always be given at the same time as the ACTH stimulation. This test measures how much ACTH the pituitary is making. A healthy ACTH value should be just into the upper third of the range assuming a range of 10-60. The ACTH plasma and ACTH stimulation test together can give a clearer picture, especially for secondary adrenal insufficiency. Interpretation for primary adrenal insufficiency and Addison's disease ACTH will be at the top or above range. In Addison's disease, ACTH can be way above range and may reach the hundreds and in rare cases reach the 1000s and 2000s. Interpretation for secondary adrenal insufficiency ACTH will usually be below 35, but not usually below the range limit. Though uncommon, values for ACTH can reach into the low 40s. 98% of people with secondary fall within range. Interpretation for aldosterone stimulation The ACTH stimulation test is occasionally used to stimulate the production of aldosterone at the same time as cortisol to also help in determining if primary hyperreninemic or secondary hyporeninemic hypoaldosteronism is present. Human ACTH has a slight stimulatory effect on aldosterone5, but the amount of synthetic ACTH given in the stimulation is equivalent to more than a whole days production of natural ACTH, so the aldosterone response can be easily measured. Same as cortisol, aldosterone should double from a respectable base value around 20 ng/dl, must fast salt 24 hours and sit upright for blood draw in a healthy individual. Interpretation for primary aldosterone deficiency The base value is usually in the mid teens or less and rise to less than double the base value thus indicating primary hypoaldosteronism potassium and renin enzyme will be high and an is an indicator of primary adrenal insufficiency or Addison's disease. Interpretation for secondary aldosterone deficiency Aldosterone production can go up by several factors from a low base value indicating secondary hypoaldosteronism potassium and renin enzyme will be low. Usually doubling to quadrupling from a low base aldosterone value is what is seen in secondary adrenal insufficiency. Decupling of aldosterone in the ACTH stimulation test is possible ie 2 ng/dl stimming to 20.6 A result of doubling of more of aldosterone may help in tandem with a cortisol stimulation that doubled or more confirm a diagnosis of secondary adrenal insufficiency. In rare cases, an aldosterone stimulation which did not double, but with the presence of low potassium, low renin and low ACTH indicates atrophy of aldosterone production from the lack of renin for an extended period. Similar to the cortisol stimulation in ACTH deficiency, a doctor may lack knowledge of how to properly interpret for secondary hypoaldosteronism and think a result of aldosterone doubling or more from a low base value is fantastic. See also Insulin tolerance test ACTH Corticotropin-releasing hormone Aldosterone Renin Cortisol Addison's disease Adrenal gland HPA axis Hypopituitarism Pituitary gland References ^ Dorin RI, Qualls CR, Crapo LM 2003. Diagnosis of adrenal insufficiency PDF. Ann. Intern. Med. 139 3: 194-204. PMID 12899587. ^ unknown. Synacthen Test PDF. ^ a b c K. Pagana, PhD, RN and T. Pagana, MD, FACS. Mosby's Diagnostic and Laboratory Test Reference 2nd ed: Adrenocorticotropic hormone stimulation test: 17. ^ K. Pagana, PhD, RN and T. Pagana, MD, FACS. Mosby's Diagnostic and Lab Test Reference 2nd ed: Aldosterone, Cortisol: 29 and 260. ^ unknown. Role of ACTH in Regulation and Action of Adrenocorticoids: 7 of 52. ^ L.A. Cunningham and M.A. Holzwarth 1988. Vasoactive intestinal peptide stimulates adrenal aldosterone and corticosterone secretion. Endocrinology 122: 2090-2097. PMID 3359977. v d e Endocrine system: hormones/endocrine glands Peptide hormones, Steroid hormones Hypothalamic-pituitary Hypothalamus: TRH, CRH , GnRH, GHRH, somatostatin, dopamine - Posterior pituitary: vasopressin, oxytocin - Anterior pituitary: α FSH, LH, TSH, GH, prolactin, POMC ACTH, MSH, endorphins, lipotropin Adrenal axis Adrenal medulla: epinephrine, norepinephrine - Adrenal cortex: aldosterone, cortisol, DHEA Thyroid axis Thyroid: thyroid hormone T3 and T4 - calcitonin - Parathyroid: PTH Gonadal axis Testis: testosterone, AMH, inhibin - Ovary: estradiol, progesterone, inhibin/activin, relaxin pregnancy Other end. glands Pancreas: glucagon, insulin, somatostatin - Pineal gland: melatonin Non-end. glands Placenta: hCG, HPL, estrogen, progesterone - Kidney: renin, EPO, calcitriol, prostaglandin - Heart atrium: ANP - Stomach: gastrin, ghrelin - Duodenum: CCK, GIP, secretin, motilin, VIP - Ileum: enteroglucagon - Adipose tissue: leptin, adiponectin, resistin - Thymus: Thymosin - Thymopoietin - Thymulin - Skeleton: Osteocalcin - Liver/other: Insulin-like growth factor IGF-1, IGF-2 Target-derived NGF, BDNF, NT-3 v d e Endocrine pathology: endocrine diseases Hypothalamic/ pituitary axes Pituitary Hyperpituitarism Acromegaly, Hyperprolactinaemia, SIADH Hypopituitarism Sheehan's syndrome, Kallmann syndrome, Growth hormone deficiency, Diabetes insipidus Adiposogenital dystrophy - Empty sella syndrome - Pituitary apoplexy - ACTH deficiency Thyroid Hypothyroidism Iodine deficiency, Cretinism, Congenital hypothyroidism, Goitre, Myxedema Hyperthyroidism Graves disease, Toxic multinodular goitre, Teratoma with thyroid tissue or Struma ovarii Thyroiditis De Quervain's thyroiditis, Hashimoto's thyroiditis, Riedel's thyroiditis Euthyroid sick syndrome - Thyroid hormone resistance - Thyroid nodule Adrenal Adrenocortical hyperfunction: Cushing's syndrome Nelson's syndrome, Pseudo-Cushing's syndrome - Hyperaldosteronism Conn syndrome, Bartter syndrome CAH Lipoid, 3β, 11β, 17α, 21α Adrenal insufficiency Addison's disease, Waterhouse-Friderichsen syndrome - Hypoaldosteronism Gonads ovarian Polycystic ovary syndrome, Premature ovarian failure testicular 5-alpha-reductase deficiency, 17-beta-hydroxysteroid dehydrogenase deficiency general Hypogonadism, Delayed puberty, Precocious puberty v d e Urinary system, physiology: renal physiology and acid base physiology Filtration Renal blood flow - Ultrafiltration - Countercurrent exchange Hormones affecting filtration Antidiuretic hormone ADH - Aldosterone - Atrial natriuretic peptide Secretion/clearance Pharmacokinetics - Clearance of medications Reabsorption Solvent drag - Na+ - Cl- - urea - glucose - oligopeptides - protein Endocrine Renin - Erythropoietin EPO - Calcitriol Active vitamin D - Prostaglandins Assessing Renal function/ Measures of dialysis Glomerular filtration rate - Creatinine clearance - Renal clearance ratio - Urea reduction ratio - Kt/V - Standardized Kt/V - Hemodialysis product - PAH clearance Effective renal plasma flow - Extraction ratio Acid base physiology Fluid balance - Darrow Yannet diagram - Body water - Interstitial fluid - Extracellular fluid - Intracellular fluid/Cytosol - Plasma - Transcellular fluid - Base excess - Davenport diagram - Anion gap - Arterial blood gas Buffering/compensation Bicarbonate buffering system - Respiratory compensation - Renal compensation Retrieved from http://en..org/wiki/ACTH_stimulation_test Categories: HPA axis | Medical tests | Blood tests | Endocrinology Views Article Discussion this page History Personal tools Log in / create account Navigation Main page Contents Featured content Current events Random article Search Go Search Interaction Community portal Recent changes Contact Donate to Help Toolbox What links here Related changes Upload file Special pages Printable version Permanent link Cite this page Languages Español Français This page was last modified on 16 August 2008, at 02:09
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