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Acth stim test interpretation
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Addison’s disease, also known as Adrenal Insufficiency or Hypocortisolism, is an endocrine disease that occurs when the adrenal glands do not produce enough of the hormone cortisol and sometimes, aldosterone. Discuss topics including symptoms and treatments for Addison’s disease.

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Acth stim test interpretation

My morning cortisol level was 3.7
So doctor spoke to an endo and he recommended doing an acth stim (I'm in the hospital currently but they don't have an endo on staff. Any ways they said I have adrenal insufficiency but would not say what type, so I'm hoping someone here can explosion the results and tell me if its addisons or secondary

Preliminary, cortisol blood level: 7.0
30min cortisol level: 16.1
60 min cortisol level: 10.6

All measurements in ug/dl
They now have me one 100mg hydrocortisone iv push every 6 hours
31 Comments Post a Comment
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657231_tn?1390151580
I am not sure why you are in the hospital - did you have surgery? I hope they find a competent endo - or can consult with one.

Your test... you did double but then you dropped so I would hope they call that a fail. It appears that they do since they have you on HC - but they have you on a dose that is more appropriate for post op and is for short term use, not long term. They are going to make you Cushingoid.

The test they did does not tell source - so no way to tell if primary or secondary. Are you tan? Do you crave salt? If you are tan, you are likely primary.

A more normal thing to do is to put you on a replacement dose. They need to titrate you down to a more normal dose or your bones will disappear (not really, but it is damaging). Too much like too little cortisol is not good.

You may also need florinef to hold sodium - do you know your sodium, potassium, renin or aldosterone readings?

BTW when you reduce to a lower dose, it may hurt as HC is an anti-inflammatory and your body will not like having it taken away. The wean should be done soon, and under supervision to get you to a normal dose. The health pages under Adrenal insufficiency should help you out.
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Avatar_f_tn
I had surgery three weeks ago and felt horrible since then, super dizzy and fainting alot and and absolutely no appetite. My cardio put me on fludrcortisone to try and raise my bp, but after 2 days on .1 mg I developed hypokalemia (I have always had.problems with my potassium getting too low) stop I was admitted when the hospitalist heard my symptoms and.how they got so much worse after surgery (my symptoms of weakness, fatigue, loss of appetite, weight loss of almost 100 pounds over the last 2 years made him order the cortisol level
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657231_tn?1390151580
I also get low K and low NA when my cortisol gets wacky - but if you hold sodium, you can hold K - so you need to increase sodium.

I take tons of salt tablets - in fact I just regularly have to take salt tabs in order to keep my BP in a normal range. I also have to take an above average dose of florinef too. It is far worse during the summer and I have to increase salt for sweating.

You will still have to titrate down. Even with no adrenals, I get 100mg during surgery, then 50mg every 6 hours for a few days, then wean back to a normal dose after 3-4 days depending on fever and all - as if you take too much cortisol it will actually have the opposite effect, you cannot heal. Keep an eye on your symptoms - fatigue goes with high cortisol as well.

Shame they took so long to figure this one out... for some reason they seem to look at cortisol last. How is your renin and alsosterone?
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Avatar_f_tn
Well I saw an endo today and he is not convinced that there is a problem with my adrenals. He said he doesn't think its my pituitary, causing the problem because my periods are regular and he said when there is a problem with the pituitary periods are the first thing to get messed up, he considers my acth stim to be borderline, because it was the low dose one and with the low dose if you go above 16, its normal and I got to 16.1,  he said the drop after was because the acth stim meds were out of my system, he also said it was reassuring that I started the test at 7. He also said that usually with addisons they see hyperkalemia, not hypokalemia like I have and sodium levels are usually on the lower end but mine were higher (but that could have been from the fludrcortisone and large amounts of iv saline in the hospital)

So he order a 21 hydroxylapse autoimmune test and he wants a repeat acth stim test in the morning and high dose.... Though I'm not sure how much different this will be result wrist than the low dose, I would think I would do better on this if I responded okay to the low dose.


However because I'm on hydrocortisone now he can't do the test right away, and I'm scheduled for surgery on wednesday this week, so because it would be worse to not treat adrenal insufficiency than to treat for a few weeks when I don't have it I'm straying on the hydro and getting stress dosing for my surgery, my current daily dose is 20 mg at 7 am and 10 mg at 6 pm so after I get back down to this dose following surgery we are going to decrease my night dose to 5mg then to nothing, so I will still be taking the am dose (except threw day of the stim test, I'll take my nothing dose late)

Idk.... I thought that adrenal insufficiency would have explained alot of my symptoms, call me crazy but I'm still kinda hoping its this, because then at least I know what IT is :s


So he ordered a 21 hydrxylapse
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657231_tn?1390151580
Er, so that 0.1 makes that much of a difference?

And I happen to know that yes, the norm is hyper-K, but there are those that are hypo-K - people do go against the norm. I am one of them and I know a few like me. It is not common, but it does happen. And it would be harder to judge your Na given all the sodium you have had. I also know a couple people - my tumor twin included (but not me) that just suddenly tank in K for unknown reasons and the reason cannot be found.

It is just not a straight thing. It all can depend on the hormones involved if your period is messed up so  some will get weird periods, some will not - it is not a definite YES or no. What I have found in hormones is that there are no absolutes. After all, I flunked all stim tests and even some so called gold standard tests for my previous disease, and pathology showed that I had it - so it is kinda hard to be that firm - the doc has to look at the entire picture - the tests, symptoms and oh yeah - you!
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Avatar_f_tn
Well I saw my primary care dr yesterday and she was not too impressed with my endo, she was like why don't I refer you to see an endo down here for a second opinion because something is obviously going on! (I live over 2 hours from my primary so this isn't ideal, but the drs trend to be much.better, like my awesome primary so I make the drive)
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657231_tn?1390151580
I like your awesome primary... as I too am not impressed with the endodud.

I also tend to have to drive - it bites but health is health... It took me a long time and I still run into duds.
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Avatar_f_tn
Well I had my arm surgery yesterday, the same exact one I had on my other arm a month ago only this time I had stress dose steroids and from the time I woke up in recovery I felt 100 times better than before! Everyone, doctors, nurses, parents noticed how much better I'm doing with the stress dose steroids.... It's amazing!!
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657231_tn?1390151580
That is great. Tapering off may take the edge off that, but it shows that you really needed them.

Heal, and feel better!
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Avatar_f_tn
Ugh I'm not looking forward to tapering, today is my last day on stress dosing at 40 mg in the am and 20 mg at night.... Tomorrow I'm supposed to go back to my regular dose at 20 mg in the am and 10mg at night but I'm wondering if that is too much of a drop I'm doing so good I'd hate to go backwards, so I'm wondering if doing 30/10 or 30/15 for a few days first might be better.... So I called endodud this morning, but have not heard back I'll try calling again soon but if I don't get through I'm going to call awesome primary for her opinion... Idk it seems to me like a slower taper wouldn't hurt and def has more potential to help than harm
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Avatar_f_tn
Ugh I'm not looking forward to tapering, today is my last day on stress dosing at 40 mg in the am and 20 mg at night.... Tomorrow I'm supposed to go back to my regular dose at 20 mg in the am and 10mg at night but I'm wondering if that is too much of a drop I'm doing so good I'd hate to go backwards, so I'm wondering if doing 30/10 or 30/15 for a few days first might be better.... So I called endodud this morning, but have not heard back I'll try calling again soon but if I don't get through I'm going to call awesome primary for her opinion... Idk it seems to me like a slower taper wouldn't hurt and def has more potential to help than harm
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657231_tn?1390151580
I can taper fast if I was just moved up in dose for a short time. So if I am sick for a short time and and I just have to dose for a day, I can move back quick without an issue, but the longer I am on the higher dose, the worse it feels to taper down.

You do have to get on a lower dose or weirdly you won't heal. Your body has a love hate relationship with cortisol - it needs it but too much or too little wreaks havoc. So you need to be on enough to get you through the stress of the surgery and a bit after to lower inflammation - then you have to be on a low enough dose that you can heal up correctly. Dosing is so much fun - part art, part science. How do you feel?
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Avatar_f_tn
Thanks for all the help rumpled!

I'm on day two of my normal dosing now 20/10 and I'm still feeling so much better than last time. Endodud did finally get back to me about tapering and I just cut back down to my regular dose like he orginally said, but over the course of the next week now I'm slowly going off the evening dose of 10mg so he can do the high dose ACTH stim which is scheduled for monday oct. 15th. Endodud also mentioned that my antibody test came back negative which is a god sign that my adrenals are working fine.... ugh not sure I agree with him.

When I was in the hospital the hospialist didn't even want to have me do the cortisol testing there because he felt that it could be elevated because I was sick and my body was so stressed at the time, but finally he just ordered it because he said if it was low then they would really know something was wrong because of how much stress my body was under then it should have been at least in the normal range if not higher. I think he was shocked when it came back so low! And it was actually 3.49 not 3.7 like I orginally wrote. Obviously that is too low for someone who is sick enough to need to be in the hospital!!! I just don't get why this endodud seems so whatever about this, both the hospitalist and my primary were shocked by the low cortisol levels and both wrote in their notes "patient was found to have a very low am cortisol of 3.49" thankfully my referral to a new endo should be sorted out some time next week, but who knows how long I will have to wait for an appt.

Rumpled, I was wondering what your thoughts were on how my endodud is having me taper and do the ACTH stim (high dose) test on the 15th. It seems to me like he is almost setting me up to fail it....

Currently I have taking 20mg at 7am and 10mg at 5:30pm I will take this until wednesday this week, then on thursday and friday I will take 20/5 and on saturday and sunday I will take only the morning dose of 20mg

Monday I hold the morning dose and go in for the high dose acth test, however my thinking is that by this point even if my adrenals were working a bit won't they be expecting that morning dose and therefore not producing as much cortisol themselves? I don't know something just doesn't seem right with how he is having me do this

Sersiously though EVERYONE is noticing how much better I have been since being on the hydrocortisone, my mood, energy, appetite everything!! It just kind of makes me scared and stressed that it looked like I finally had the answer to everything and now endodud is trying to squash that.... I know it's weird to be wanted to be told something is worng with you but it is so much better when they actually know what is wrong with you and have a treatment that works!

Currently still going along with endodud and his testing but hoping the appt for a 2nd opinion with an endo comes through quickly and they are good!
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657231_tn?1390151580
From what I know the antibody test just means you don't have Addison's disease which is the auto immune type but you can still have adrenal insufficiency.  They can be atrophied or the pit can be wonked.

As for the stim test, I never heard of doing that way.  Out of my knowledge base and it does seem a bit strange.  I agree with the other docs that your body should have been fighting hard and to have a low then was wrong.

Glad you are getting another opinion.  I wonder if we should get "I went to an endodud and all I got was this lousy t-shirt" printed up...
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Avatar_f_tn
Well the endocrinology clinic my awesome primary referred me to called today and they had reviewed my records and asked me a few questions and the girl on the phone goes: "well it def sounds like you have adrenal insufficiency" !! Wow i like them sounds like they know what they are doing!! They got me an appt for nov 5th, and they called endodud's office to make sure the fax the stim tests results on monday, she said 5th was their first opening but if i wasn't feeling good to call and they would work me in sooner she also said to be sure to return to my normal 20\10 hc dose after the stim test and to start on it until in see them.

I must say I'm excited to see them, they sound great and like they know what they are doing!!

Although my appt monday with endodud may be a bit akward because he will now know I'm dumping him and moving on to better people :)
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657231_tn?1390151580
Glad the doc decided to go on tests rather than run more.  Most want to run more and it just takes time and money.

The new group for sure sounds up on things so glad you can dose and stay safe.

Poor endodud....
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Avatar_f_tn
Hey rumpled, last night was my first night down to 5mg at night and today im starting to have dizzy spells when I go from sitting to standing, they are no where near as bad as when I was on no hc (then it was full blackouts and faints) can the small 5mg change at night be to blame for this? Our is it a coincidence? I mean I'm still taking the 20mg in the am so I'm not sure if a small decease in my evening dose could be blamed for problems during the day?
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Avatar_f_tn
Hey rumpled, last night was my first night down to 5mg at night and today im starting to have dizzy spells when I go from sitting to standing, they are no where near as bad as when I was on no hc (then it was full blackouts and faints) can the small 5mg change at night be to blame for this? Our is it a coincidence? I mean I'm still taking the 20mg in the am so I'm not sure if a small decease in my evening dose could be blamed for problems during the day?
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657231_tn?1390151580
Uh... it could be a factor. Are you on any florinef at all? If not, the the corticosteroid is the only thing keeping your BP up.

The sitting to standing BP drop is called POTS - you can look it up - postural orthostatic tachycardia syndrome or something like that - and lots of us (and others for no reason) get it. It is treated with florinef or just making sure when you change position, you know, take care, and don't go too fast - so in the mean time, take care! I used to have a big issue just cleaning out the cat litter so yeah, it is a pain.

I also take salt (which you would have to do under docs orders - I do under mine) to keep my BP up. If you crave salt in any way though I would suggest that you call your doc and follow what your body is saying. And just be careful changing positions... I sometimes use a home BP monitor to check things out and I recently had to up more florinef dose to an above normal dose to help me out. Low BP is not fun.
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Avatar_f_tn
I'm not currently on florinef... but I was that was actually pretty much what lead to be being in the hospital in the first place because after only two days on .1mg 1x daily I ended up with a potassium level of 2.6 :( so they didn't want me to be taking that. However when on my 20/10 dosing of the HC I had no problems with the dizzy spells so I think it's just being carefull until my HC is back to normal. I have always had low bp just in general usually around 90/60, but when on the HC my bp was consistantly around 110/70, so it was doing something. Salt tablets would be okay because I'm supposed to be on a high sodium diet (because of the dizzy and fainting spells) but I've been trying to do that by diet alone because I really don't think I'll be able to tolerate the salt tablets because I have a very sensitive stomach (although this greatly improved on the HC too!!)

I'm feeling pretty crappy today and am not looking forward to holding my morning dose of HC for the ACTH stim test tomorrow... I have to be up at 7am, and be on the road by 7:30 at the latest to make it in time for my appt at 8:30 I hope the stress of the commute and such won't mess up the test! I'm also fasting... which makes me wonder if the results of my last stim test were effected by the fact that I wasn't fasting... lol actually I think I'm hoping that the reason I went up to 16.1 was some how only because it wasn't fasting!

Keeping my fingers crossed that everything goes well tomorrow!! I know I have the appt with the new endo nov. 5th and she sounds like she knows what she is doing but I'd really feel much better if I could get endodud on board and get a solid diagnosis vs all these conflicting opinions. It's weird to be hoping for abnormal results, but I have felt so much better on the HC and I'm really hoping this is the answer to everything!! If the ACTH stim doesn't go well and endodud is still being a dud I may see what he thinks about doing the insulin tolerance test, for what I've read it seems to be a bit more accurate than the stim test.

Oh, and you know what I realized about a year ago I had some dental work done and I had to be sedated (due to severe anxiety and large amount of work needed)  well the dentist gave me a dose of steriods to help with the swelling and stuff after (he choose the steriod because I'm allergic to nsaids) anyways after I was done I wasn't tired or sick feeling at all in fact I made my mom take me shopping and she was shocked by how energized I was.... it kinda makes sense now why I felt so good!

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657231_tn?1390151580
They put you on florinef without telling you to up sodium? As florinef helps you hold sodium and sodium and potassium work together... the doc should have put you on salt tabs with the florinef before. I always got salt with my florinef - so you needed it before.

Sodium is used in a lot of things used for bad tummies - so hopefully the extra sodium and the tablets will help. I sometimes go for alka seltzer or other fizzy high sodium things to help ( I get some at Italian food stores) - it can also just help for raising your BP.

Someone will be with you tomorrow? Insulin is just another stim agent - they can vary... and some are harder on the body than others.
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Avatar_f_tn
Well my stim test and appt did not go too well this morning. First off I was super anxious/stressed out and had trouble sleeping this moring (kept waking up early and couldn't fall back asleep despite being super tired) then I got distracted on my hour long drive to the clinic and missed a turn which lead to a 10 mile detour, and making me very tight on time for my appt at 8:30 so I was freaking out I may not make it on time. I did make it on time, but the clinic had no idea what they were doing and didn't get my first lab drawn until 9:15! and then it took them 3 attempts to do it and the draw they finally did get was long a difficult, so I'm guessing all this affected the results some. Also the only labs endodud ordered were baseline cortisol and 60 min cortisol.

Then because they started late the 60 min cortisol level wasn't ready for my appt with endodud. My baseline cortisol was 9, which he said was normal and fine and he kept stating that he didn't think I had a problem with my adrenals... then he was like we got a call from another place they want your records? lol talk about akward he actually refused to send the test results or notes to my new endo because they never gave him a "name" only a number... but he will send it to my primary! whatever, my primary will make she the endo gets it!!

I left very frustrated, I called back this afternoon and the nurse said my response to the high dose acth was "inadequate" and that the doctor wants me to resume taking the hc 20/10... I asked her what number my cortisol got to... 10.2 only!

still no official diagnosis I'm supposed to see him again in 6 weeks but I'm guessing I'll just end up following with the new endo.

Idk... maybe that 9 was normal but a response to the high dose acth of only 10.2 def is not!

endodud didn't even seem to care that I felt so much better on the hc, he seems like a dr that only treats numbers he sees on paper, and doesn't consider the patient and their symptoms.... and that is def not a good dr!!
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Avatar_f_tn
Uf... Now I feel like I'm starting to get sick, bad headache, sinus congestion, sore throat and fever(101.2) and chills.... Endodud never talked to me about stress dosing for this, do I need to stress dose, if so what dosage for how long? Ugh.... Guess I need to call tomorrow and see what if anything I'm supposed to do, I'm sure it's just virus and will pass in a few days but my gut is telling me I may be better off with some small stress dosing. Rumpled what is typical in this case?
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657231_tn?1390151580
That was a fail on the high dose test - and weird that they are still putting you off on visits - although 6 weeks is pretty fast for endos these days.

If you are getting sick, you need to push fluids, and I would up salty things - and there are some guidelines in the health pages - I will post the link. With a fever that high, I add anywhere from 10-20mg, and make sure I rest, keep a bucket close by (I tend to vomit any time I get ANY illness), and go for tomato juice and stuff that will keep up your sodium and potassium. Gatorade and V-8 will work. You only need to stress dose while you have the fever.

I hope the new doc is better!
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657231_tn?1390151580
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Avatar_f_tn
Thanks for the link! The next still felt really crappy and woke up at 5am feeling horrible, so I took my hc early but didn't stress dose because my fever was gone. now it just feels like a bad cold/upper respiratory infection but no fever. Today however I started feeling really crappy and like I had before I started the hc (weak, shaky, fatigued, nauseated, no appetite, craving salt) some of those could be the cold too... But then I found out a nasty stomach virus is going around work so I called endodud to see if I should stress dose, he does want me to stress dose... But it's bigger than I thought it would be! I'm supposed to double until I feel better.... Hmmm that's a bit of a change from the last time I saw him and he told me he think my adrenals are fine and we should, start tapering!
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657231_tn?1390151580
I hope you upped salt if you craved it. When I feel horrid, I go for tomato juice (I get low K too) and add sea salt and lemon (it just tastes a bit better) and add some water as it can be a bit thick. Sea salt just tastes better without the bitter taste of regular salt. No one gives me perfume - just different salts LOL....

Stay on top of it - if your tummy is still bad, try fizzy sodium bicarbonate stuff - that is high is sodium and so it will help the salt issue as well! Woohoo!

Endodud is finally coming around... about dang time.
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Avatar_f_tn
yup have definitly been trying to up the salt intake. I really don't like tomato juice or fizzy drinks but I made some homemade sweet potato soup for the potassium, and we only had low sodium broth but I added a ton of salt to it!! I've also been drinking powerade and eating tostitos a lot!

My tummy started to feel better a hour or two after I took the extra HC so I'm thinking that was mostly related to not having enough cortisol rather than the start of a stomach virus. It feels like my cold is starting to settle in my chest though, which tends to happen with me a lot so hopefully it doesn't progress to something worse.

Yup, endodud finally got his test result with the numbers showing that something is going on!
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657231_tn?1390151580
I never used to like tomato juice so I can relate - hence the lemon. I don't drink sodas (except seltzer) but I discovered bicarbonate stuff after my hubs Italian aunt gave me this fizzy lemon stuff after stuffing us all with way too much food on the holidays.

Feel better and rest up.
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Avatar_f_tn
Well today I called endodud's office to see what he was thinking as far a long treatment, like if he was still planning on tapering me off the steroids and I wanted to know what he was thinking as far a dx and let me say he surprised me... Turned a 360, said there will be no stopping the steroids and that I have primary adrenal insufficiency, I have a dx!
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657231_tn?1390151580
WOW! sounds like he got him an edumacation LOL... [sic]

Hope you start on the upswing soon and the new endo helps you more.
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rumpled
Northern, NJ