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ACTH following overnight dexamethasone suppression can be used in the verification of autonomous cortisol secretion in patients with adrenal incidentalomas

Puvaneswaralingam, Shobitha ; Kjellbom, Albin LU ; Lindgren, Ola LU ; Löndahl, Magnus LU and Olsen, Henrik LU (2021) In Clinical Endocrinology 94(2). p.168-175
Abstract

Objective: During the investigation of adrenal incidentalomas, it is important to accurately diagnose autonomous cortisol secretion (ACS) but the specificity of cortisol ≥50 nmol/L after overnight dexamethasone suppression (cortisolONDST) is low. Therefore, ACTH following overnight dexamethasone suppression (ACTHONDST) and cortisol following a 2-day dexamethasone suppression test (cortisol2-DAYDST) were examined as markers of HPA axis suppression during ONDST. Design: This cross-sectional study examined patients with adrenal incidentalomas and basal ACTH ≥ 2.0 pmol/L who underwent ONDST. Measurements: ACTHONDST/ACTH ratio (ACTH ratio) was calculated for all patients. To define cut-off levels... (More)

Objective: During the investigation of adrenal incidentalomas, it is important to accurately diagnose autonomous cortisol secretion (ACS) but the specificity of cortisol ≥50 nmol/L after overnight dexamethasone suppression (cortisolONDST) is low. Therefore, ACTH following overnight dexamethasone suppression (ACTHONDST) and cortisol following a 2-day dexamethasone suppression test (cortisol2-DAYDST) were examined as markers of HPA axis suppression during ONDST. Design: This cross-sectional study examined patients with adrenal incidentalomas and basal ACTH ≥ 2.0 pmol/L who underwent ONDST. Measurements: ACTHONDST/ACTH ratio (ACTH ratio) was calculated for all patients. To define cut-off levels for ACTHONDST and ACTH ratio as markers of HPA axis suppression, ROC curves were used to separate patients with cortisolONDST <50 and ≥50 nmol/L. Results: CortisolONDST was ≥50 nmol/L in 140 out of 373 patients. In patients with cortisolONDST <50 nmol/L, ACTHONDST was 0.28 pmol/L (<0.23–2.7). DHEAS was positively correlated to ACTHONDST, demonstrating a 9% increase with a doubling in ACTHONDST, p = 0.02. The best cut-off levels for ACTHONDST and ACTH ratio to detect cortisolONDST ≥50 nmol/L were ≥0.6 pmol/L and ≥18% respectively. These cut-off levels were tested on patients with cortisolONDST <50 nmol/L, considered to have adequate suppression (n = 233), and patients with reduction of ≥50 nmol/L from cortisolONDST to cortisol2-DAYDST, who were considered to have inadequate suppression (n = 16). ACTHONDST ≥0.6 pmol/L and ACTH ratio ≥18% had a sensitivity of 75% and 81% respectively, and a specificity of 78% and 85% respectively, for detecting patients with inadequate suppression. Conclusions: ACTHONDST and ACTH ratio can be markers of HPA axis suppression in the investigation of adrenal incidentalomas. CortisolONDST ≥50 nmol/L with ACTHONDST <0.6 pmol/L or ACTH ratio <18% should lead to the suspicion of ACS.

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; ; ; and
organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
adrenal incidentaloma, adrenocortical adenomas, adrenocorticotropic hormone, adult, cross-sectional studies, dexamethasone, hypothalamic–pituitary–adrenal axis
in
Clinical Endocrinology
volume
94
issue
2
pages
168 - 175
publisher
Wiley-Blackwell
external identifiers
  • pmid:33108675
  • scopus:85096658576
ISSN
0300-0664
DOI
10.1111/cen.14357
language
English
LU publication?
yes
id
aa936c6b-8e78-4168-b70b-ca90b4d2e80a
date added to LUP
2020-12-07 14:55:51
date last changed
2021-04-16 16:57:51
@article{aa936c6b-8e78-4168-b70b-ca90b4d2e80a,
  abstract     = {<p>Objective: During the investigation of adrenal incidentalomas, it is important to accurately diagnose autonomous cortisol secretion (ACS) but the specificity of cortisol ≥50 nmol/L after overnight dexamethasone suppression (cortisol<sub>ONDST</sub>) is low. Therefore, ACTH following overnight dexamethasone suppression (ACTH<sub>ONDST</sub>) and cortisol following a 2-day dexamethasone suppression test (cortisol<sub>2-DAYDST</sub>) were examined as markers of HPA axis suppression during ONDST. Design: This cross-sectional study examined patients with adrenal incidentalomas and basal ACTH ≥ 2.0 pmol/L who underwent ONDST. Measurements: ACTH<sub>ONDST</sub>/ACTH ratio (ACTH ratio) was calculated for all patients. To define cut-off levels for ACTH<sub>ONDST</sub> and ACTH ratio as markers of HPA axis suppression, ROC curves were used to separate patients with cortisol<sub>ONDST</sub> &lt;50 and ≥50 nmol/L. Results: Cortisol<sub>ONDST</sub> was ≥50 nmol/L in 140 out of 373 patients. In patients with cortisol<sub>ONDST</sub> &lt;50 nmol/L, ACTH<sub>ONDST</sub> was 0.28 pmol/L (&lt;0.23–2.7). DHEAS was positively correlated to ACTH<sub>ONDST</sub>, demonstrating a 9% increase with a doubling in ACTH<sub>ONDST</sub>, p = 0.02. The best cut-off levels for ACTH<sub>ONDST</sub> and ACTH ratio to detect cortisol<sub>ONDST</sub> ≥50 nmol/L were ≥0.6 pmol/L and ≥18% respectively. These cut-off levels were tested on patients with cortisol<sub>ONDST</sub> &lt;50 nmol/L, considered to have adequate suppression (n = 233), and patients with reduction of ≥50 nmol/L from cortisol<sub>ONDST</sub> to cortisol<sub>2-DAYDST</sub>, who were considered to have inadequate suppression (n = 16). ACTH<sub>ONDST</sub> ≥0.6 pmol/L and ACTH ratio ≥18% had a sensitivity of 75% and 81% respectively, and a specificity of 78% and 85% respectively, for detecting patients with inadequate suppression. Conclusions: ACTH<sub>ONDST</sub> and ACTH ratio can be markers of HPA axis suppression in the investigation of adrenal incidentalomas. Cortisol<sub>ONDST</sub> ≥50 nmol/L with ACTH<sub>ONDST</sub> &lt;0.6 pmol/L or ACTH ratio &lt;18% should lead to the suspicion of ACS.</p>},
  author       = {Puvaneswaralingam, Shobitha and Kjellbom, Albin and Lindgren, Ola and Löndahl, Magnus and Olsen, Henrik},
  issn         = {0300-0664},
  language     = {eng},
  number       = {2},
  pages        = {168--175},
  publisher    = {Wiley-Blackwell},
  series       = {Clinical Endocrinology},
  title        = {ACTH following overnight dexamethasone suppression can be used in the verification of autonomous cortisol secretion in patients with adrenal incidentalomas},
  url          = {http://dx.doi.org/10.1111/cen.14357},
  doi          = {10.1111/cen.14357},
  volume       = {94},
  year         = {2021},
}