ACTH Stim test

[compnet]

Hello!

I finally got my records for the stim test.


Keep in mind that the IV nurse messed up and gave me the HIGH DOSE of the test, which I read can stim very well even partial, new or secondary adrenals -- that was the reason I was trying for the low-dose, as it's supposed to be more sensitive. Also, they did it starting at 9:30AM, so, not much I could do about that.



250 MCG ACTH STIMULTION TEST


1/20/11


-------------Baseline-----30min-----------60min

Cortisol ____8.0______20.4_______25.0

ACTH _____11

Aldosterone __2________10_______14

DHEA-S ___241

Renin ______2.36_______2.09_____1.93


________________________________


Measures and ref:


Cortisol greater than 18-20 mcg/dL

ACTH 5-27 pg/mL

Aldosterone < or = 28 ng/dL

DHEA-s 45-320 mcg/dL

Renin 0.25-5.82 ng/mL/hr



I'm glad to see my DHEA-s went up from 117 or so.


8.0 cortisol and 11 ACTH are the lowest either have gone, so far documented.


Yesterday, I went in for AM cortisol w/ACTH, and the same that night, so we'll see how that looks.


I'm thinking about asking for the Metryapone Test...


"The low-dose ACTH Stimulation Test is intermediate in sensitivity between the metyrapone test and the insulin-induced hypoglycemia or high-dose ACTH stimulation test. It may detect more subtle deficiency in cortisol secretion than the latter because plasma ACTH does not increase as much; however, the clincial importance of this finding is uncertain."

______________________________________

"In 2 cases of acute pituitary dysfunction, however, the Cortrosyn test was normal whereas the ITT was not (13)."


"Cortrosyn test may be misleading, as shown in a study demonstrating normal Cortrosyn test results but abnormal ITT responses in patients with pituitary disease (15)."


"...although normal Cortrosyn but abnormal ITT responses have been seen up to 3 months after pituitary surgery (16)."


"Furthermore, patients with a subnormal response to the Cortrosyn test demonstrate a smaller perioperative increase in cortisol than that seen in the patients with a normal Cortrosyn but abnormal insulin tolerance or metyrapone test (18). In contrast, abnormal metyrapone responses have been demonstratedin patients previously receiving high dose glucocorticoid therapy who have a normal Cortrosyn test. However, the data do not permit a comparison to be made between..."


"The metyrapone test may be the most sensitive method for detecting adrenal insufficiency."

______________________________

"It has been shown that a single ACTH stimulation test misses the majority of FM/CFS patients that have adrenocortical deficiency, but when a combination of stimulation tests are used, such as metyrapone test, or more sophisticated analysis is used, close to 100% of these individuals have documented adrenocortical dysfunction."


"It should be considered the standard of care to treat patients with CFS and FM who have baseline cortisol levels under 12 ug/ml."


"In summary, it is becoming clear that the majority of patients with CFS and FM suffer from clinically significant adrenocortical dysfunction and that physiologic replacement of cortisol is an appropriate intervention in these patients. Cortisol doses of 5-15 mg/day have been shown to be safe, with little associated risk including adrenal suppression, and have the potential for significant clinical benefit. The current evidence supports the use of physiologic doses of cortisol in the treatment of CFS and FM, and a therapeutic trial of cortisol should be considered in these patients, especially those with basal cortisol levels less than 12 ug/dl."


"A study published in the Brazilian Journal of Infectious Disease (figure 2) demonstrates that in this type of patient population a baseline cortisol level of less than 12 has a specificity of greater than 90% for adrenocortical dysfunction and a level less than 10 ug/dl has a specificity of 98% for adrenocortical dysfunction."

___________________

All your thoughts, please!

[rumpled]

I have heard two cutoffs - the doubling and one that is 32 or 37  (I forget, my brain...) and on the second, you failed. It was discussed in another thread too.

Using the 600nmol/l if you convert, you had 695.5 (unless I messed that up, math is hard...) so that means you failed there too.

Bags= yeah, not optimal... ACTH for sure needs a spin within minutes.

I hope someone can help you with the other test - I don't know anyone who has taken it.

[compnet]

I've been talking on Dusty's addison board, and one of the members has pointed out that newer studies are showing that the 30 min cut off is 600 nmol/l, which I failed.  It looks like secondary AI, and maybe not as severe as most cases.

I saw them put tubes in bags, and I don't know what from there...

Renin and aldosterone was recommended by some people on Dusty's adrenal board.

I'm pretty sure that low-dose would have been a better identifier of a problem.  

I'm planning on asking for the Metyrapone test as it is more sensitive, this test can be interpreted so many ways, and I'm looooooooong symptomatic.

Does anyone here know when the BASELINE is supposed to be drawn in the Metyrapone Test?  Is it midnight, right before medicine administration; or, is it 8AM BEFORE the evening you are admitted to the hospital?

[rumpled]

I have seen interpretations that go a couple of ways but your stim test may get interpreted as normal as you did more than double - so you did react to the stress (however the nurse did mess up the test...)
ACTH - did they put the tube in the bin?
I have never seen them do renin and aldosterone as part of the stim test... has anyone else?

As for the accuracy of the test - ah - I would hazard it misses people - borderline, and those that ok now but not for long for instance but still symptomatic... I don't know a perfect test.