{ "schemaVersion": 2, "eyebrow": "Endocrinology", "title": "Adrenal Insufficiency Diagnostic Testing", "summary": "Test promptly when otherwise unexplained hypotension, volume depletion, hyponatremia, hyperkalemia, abdominal pain, fever, or hypoglycemia raises concern. Draw cortisol and ACTH when feasible, but treat suspected crisis immediately, then use cosyntropin testing and ACTH-directed classification to define primary versus central disease.", "seoDescription": "Physician guide to adrenal insufficiency testing: emergency sampling, morning cortisol, ACTH, cosyntropin interpretation, and primary versus central classification.", "clinicalQuestion": "How should clinicians test for adrenal insufficiency while avoiding delay in treatment of adrenal crisis?", "specialty": "Endocrinology", "audience": "U.S. physicians and medical trainees", "tags": [ "adrenal insufficiency testing", "morning cortisol", "ACTH", "cosyntropin stimulation test", "adrenal crisis", "primary adrenal insufficiency", "secondary adrenal insufficiency" ], "keyTakeaways": [ "In suspected adrenal crisis or severe adrenal insufficiency, give parenteral hydrocortisone immediately; do not await diagnostic results. [14][22][23]", "Obtain early-morning serum cortisol and plasma ACTH concurrently when the patient is stable enough for testing; ACTH greater than twice the assay upper limit supports primary adrenal insufficiency. [18][19]", "Use the standard 250-mcg cosyntropin stimulation test as confirmatory testing when clinical circumstances permit; a normal stimulated cortisol threshold depends on assay and sampling method. [20][23]", "A cosyntropin test documents impaired adrenal reserve but does not independently distinguish primary from chronic central adrenal insufficiency; classify with ACTH and assess renin and aldosterone when primary disease is suspected. [18][19][23]", "Do not use a reassuring cosyntropin response to exclude newly acquired secondary or tertiary adrenal insufficiency without considering timing and pretest probability. [20]" ], "sections": [ { "id": "triage-and-emergency-sampling", "eyebrow": "Immediate decision", "heading": "When suspected adrenal crisis overrides diagnostic sequencing", "intro": "Stabilize first when the presentation suggests cortisol-deficient shock or severe illness.", "paragraphs": [ "Test acutely ill patients for primary adrenal insufficiency when otherwise unexplained volume depletion, hypotension, hyponatremia, hyperkalemia, fever, abdominal pain, hyperpigmentation, or—particularly in children—hypoglycemia is present. [14][22][23]", "For severe symptoms or suspected adrenal crisis, administer hydrocortisone before diagnostic results return. The recommended emergency regimen is 100 mg hydrocortisone intravenously or intramuscularly immediately, with fluid resuscitation, then 200 mg hydrocortisone over 24 hours by continuous intravenous infusion or 50 mg intravenously or intramuscularly every 6 hours. [22][24]", "If doing so does not delay therapy, obtain serum cortisol and plasma ACTH before the first glucocorticoid dose. Once initial samples are drawn, high clinical suspicion warrants steroid treatment even before confirmatory testing; defer dynamic testing until the patient is clinically stable. [19][22]" ], "bullets": [ "Admit patients unable to absorb oral glucocorticoid during prolonged vomiting or diarrhea; give 100 mg intravenous or intramuscular hydrocortisone. [24]", "In severe illness such as sepsis or intensive-care admission, continue 200 mg intravenous hydrocortisone per 24 hours after the initial emergency dose. [24]" ], "subsections": [], "table": { "caption": "Emergency testing and treatment sequence for suspected adrenal crisis. [22][24]", "columns": [ "Clinical state", "Immediate action", "Testing implication" ], "rows": [ [ "Severe symptoms or suspected adrenal crisis", "Hydrocortisone 100 mg IV or IM immediately; give fluid resuscitation. [22]", "Draw cortisol and ACTH first only if this does not delay treatment. [19][22]" ], [ "Persistent severe illness after initial dose", "Hydrocortisone 200 mg IV over 24 hours or 50 mg IV/IM every 6 hours. [22][24]", "Perform confirmatory adrenal-axis testing after stabilization. [22][23]" ], [ "Prolonged vomiting or diarrhea preventing oral absorption", "Hospitalize and give hydrocortisone 100 mg IV or IM. [24]", "Oral replacement cannot be relied on during this interval. [24]" ] ] } }, { "id": "initial-biochemical-evaluation", "eyebrow": "First-line testing", "heading": "How to use morning cortisol and ACTH", "intro": "Interpret basal cortisol in context, then use ACTH to localize the defect.", "paragraphs": [ "In a hemodynamically stable patient with suspected adrenal insufficiency, measure an early-morning serum cortisol with plasma ACTH collected concurrently. ACTH is the key discriminator after low or inappropriately low cortisol: an ACTH concentration greater than twice the upper limit of normal at any time of day is consistent with primary adrenal insufficiency, whereas low or inappropriately normal ACTH indicates secondary or tertiary disease. [18][19][20]", "Basal cortisol can triage the need for dynamic testing, but cutoffs are assay- and center-dependent. In an observational cohort of 804 patients undergoing cosyntropin testing, basal cortisol at least 450 nmol/L had a 98.7% negative predictive value for adrenal insufficiency; basal cortisol values of 100 nmol/L or lower and 450 nmol/L or higher had high diagnostic accuracy in that cohort. [10]", "Do not apply a single basal cortisol threshold as a universal exclusion rule. Current diagnostic strategy still recommends corticotropin stimulation testing for patients with symptoms or signs suggesting primary adrenal insufficiency when their condition permits, and contemporary commentary emphasizes limitations of single cortisol measurements. [7][23]" ], "bullets": [ "Order ACTH with—not after—the initial morning cortisol, because delayed ACTH sampling can obscure primary versus central classification. [18][19]", "For suspected primary adrenal insufficiency, obtain plasma renin and aldosterone simultaneously to identify mineralocorticoid deficiency. [23]", "Elevated renin with low aldosterone increases suspicion for primary adrenal insufficiency in the appropriate clinical setting. [19]" ], "subsections": [], "table": { "caption": "Initial biochemical patterns and the next diagnostic action. [10][18][19][23]", "columns": [ "Pattern", "Interpretation", "Next action" ], "rows": [ [ "Morning cortisol ≥450 nmol/L", "In one 804-patient cohort, negative predictive value for adrenal insufficiency was 98.7%. [10]", "If pretest probability remains high, do not rely on a single value; proceed according to clinical context and dynamic-test strategy. [7][23]" ], [ "Morning cortisol ≤100 nmol/L", "Had high diagnostic accuracy for adrenal insufficiency in the observational cohort. [10]", "Measure concurrent ACTH and promptly establish the etiologic branch; treat without delay when clinical suspicion is high. [19]" ], [ "Low cortisol with ACTH >2× upper limit of normal", "Consistent with primary adrenal insufficiency. [18][19]", "Measure renin and aldosterone and pursue primary adrenal etiologic evaluation. [23]" ], [ "Low cortisol with low or inappropriately normal ACTH", "Suggests secondary or tertiary adrenal insufficiency. [20]", "Evaluate the central hypothalamic-pituitary axis; recognize that acute central disease may have a falsely reassuring cosyntropin response. [20]" ] ] } }, { "id": "cosyntropin-testing", "eyebrow": "Dynamic testing", "heading": "When and how to interpret cosyntropin stimulation testing", "intro": "Use dynamic testing to confirm impaired adrenal reserve in stable patients.", "paragraphs": [ "Use a corticotropin stimulation test to confirm suspected primary adrenal insufficiency when the patient is clinically stable enough to undergo testing. The Endocrine Society guideline recommends the standard 250-mcg test for most patients and reserves the 1-mcg low-dose test for primary adrenal insufficiency when standard corticotropin is in short supply. [20][23]", "A standard 250-mcg cosyntropin test can be performed at any time of day. In the cited clinical review, a cortisol value greater than 18 to 20 mcg/dL after intravenous cosyntropin excluded adrenal insufficiency; after intramuscular administration, a 30-minute value greater than 16 to 18 mcg/dL excluded adrenal insufficiency. These thresholds require alignment with the local assay and protocol. [20]", "A blunted cosyntropin response confirms deficient adrenal reserve but does not establish adrenal versus central pathology. Chronic ACTH deficiency can produce adrenal hyporesponsiveness, so an abnormal response occurs in secondary disease as well as primary disease; use ACTH rather than the cosyntropin result alone to classify the disorder. [18][19]" ], "bullets": [ "Do not infer primary adrenal insufficiency solely from an abnormal cosyntropin test. [18][19]", "Do not use a standard cosyntropin test to exclude acute secondary or tertiary adrenal insufficiency, because adrenal responsiveness may still be preserved early after central ACTH deficiency develops. [20]", "Low-dose and high-dose corticotropin tests had comparable results in the primary adrenal insufficiency workup in the Endocrine Society guideline evidence review; low-dose testing may be more sensitive for secondary disease, but is not the routine primary-adrenal-insufficiency test. [22][23]" ], "subsections": [ { "heading": "When to consider specialized central-axis testing", "paragraphs": [ "When clinical suspicion for secondary adrenal insufficiency remains high despite non-diagnostic testing, insulin tolerance testing or overnight metyrapone testing may identify central adrenal insufficiency. These tests should be selected and interpreted with endocrinology involvement. [11][19]" ], "bullets": [ "Use specialized testing particularly when recent-onset central ACTH deficiency is plausible and standard cosyntropin testing may not exclude it. [20]", "Interpret insulin tolerance and metyrapone tests in a setting able to manage test-specific risk and assay-dependent thresholds. [11][19]" ] } ], "table": { "caption": "Dynamic-test selection and limitations in suspected adrenal insufficiency. [18][19][20][22][23]", "columns": [ "Test", "Best use", "Key interpretation or limitation" ], "rows": [ [ "Standard 250-mcg cosyntropin stimulation test", "Confirm suspected primary adrenal insufficiency in stable patients. [20][23]", "Post-IV cortisol >18–20 mcg/dL excluded adrenal insufficiency in the cited review; use assay-appropriate local thresholds. [20]" ], [ "Low-dose 1-mcg corticotropin test", "Alternative for primary adrenal insufficiency only when standard corticotropin is unavailable. [23]", "May have greater sensitivity for secondary adrenal insufficiency, but is not the guideline-preferred routine test for primary disease. [22][23]" ], [ "Insulin tolerance test", "Evaluate selected suspected central cases. [11][19]", "Requires endocrinology-supervised selection and interpretation. [19]" ], [ "Overnight metyrapone test", "Evaluate selected suspected central cases. [11][19]", "Requires endocrinology-supervised selection and interpretation. [19]" ] ] } }, { "id": "primary-versus-central-classification", "eyebrow": "Etiologic branch", "heading": "What changes after abnormal testing", "intro": "Use ACTH and mineralocorticoid testing to separate adrenal failure from central ACTH deficiency.", "paragraphs": [ "After documenting adrenal insufficiency, classify primary versus central disease immediately because mineralocorticoid evaluation and replacement apply to primary disease. Primary adrenal insufficiency requires lifelong glucocorticoid and mineralocorticoid replacement, whereas secondary adrenal insufficiency reflects impaired pituitary ACTH secretion and tertiary disease impaired hypothalamic corticotropin-releasing hormone signaling. [19][20]", "For the primary pattern—low cortisol with elevated ACTH—measure renin and aldosterone to determine mineralocorticoid deficiency. Confirmed aldosterone deficiency is an indication for fludrocortisone replacement, in addition to glucocorticoid replacement. [23]", "For the central pattern—low cortisol with low or inappropriately normal ACTH—evaluate for pituitary or hypothalamic structural causes when clinically indicated; adrenal imaging and pituitary imaging can identify structural etiologies in their respective branches. [7]" ], "bullets": [ "Hyperkalemia, elevated renin, and low aldosterone reinforce a primary-adrenal pattern. [19][23]", "A cosyntropin result cannot replace ACTH for primary-versus-central classification. [18][19]", "Initiate glucocorticoid therapy without delay once adrenal insufficiency is established, or earlier after diagnostic samples when suspicion is high. [19]" ], "subsections": [], "table": { "caption": "Primary and central adrenal insufficiency: classification tests that alter management. [18][19][20][23]", "columns": [ "Feature", "Primary adrenal insufficiency", "Secondary or tertiary adrenal insufficiency" ], "rows": [ [ "ACTH with low cortisol", "ACTH >2× upper limit of normal supports primary disease. [18][19]", "ACTH is low or inappropriately normal. [20]" ], [ "Mineralocorticoid evaluation", "Measure plasma renin and aldosterone; confirmed aldosterone deficiency supports fludrocortisone replacement. [23]", "The cited guideline specifically directs renin and aldosterone testing for primary disease. [23]" ], [ "Role of cosyntropin result", "Confirms impaired reserve but does not by itself prove adrenal pathology. [18][19]", "Chronic central ACTH deficiency may yield an abnormal response; acute central disease may not be excluded by testing. [18][20]" ], [ "Structural evaluation", "Adrenal imaging may elucidate structural causes when indicated. [7]", "Pituitary imaging may elucidate structural causes when indicated. [7]" ] ] } }, { "id": "testing-pitfalls-and-follow-up", "eyebrow": "Avoid misclassification", "heading": "Common testing traps and operational follow-up", "intro": "Interpret results against illness severity, timing, and the suspected anatomic level of disease.", "paragraphs": [ "Do not postpone emergency hydrocortisone for a technically ideal stimulation test. In severe suspected adrenal insufficiency, the clinical priority is immediate stress-dose therapy, with diagnostic confirmation and etiologic classification pursued after stabilization. [14][22][23]", "Avoid interpreting a delayed ACTH result as if it were paired with the original cortisol. Concurrent early-morning cortisol and ACTH sampling gives the most reliable primary-versus-central distinction, while dynamic testing assesses reserve rather than disease location. [18][19][20]", "In patients receiving exogenous corticosteroids or with concern for treatment-related suppression, recognize that systemic corticosteroid exposure is associated with adrenal insufficiency and that inhaled fluticasone has been associated with impaired adrenal responses in bronchiectasis cohorts. A medication history should therefore precede interpretation of a suspected central pattern. [4][15]" ], "bullets": [ "Refer for endocrinology-guided insulin tolerance or metyrapone testing when standard testing is discordant with a high-probability central presentation. [11][19]", "For a confirmed primary pattern, complete renin-aldosterone assessment rather than assuming glucocorticoid deficiency alone. [23]", "For future vomiting, diarrhea, sepsis, or inability to take oral glucocorticoids, patients with established adrenal insufficiency need parenteral hydrocortisone rather than routine oral dosing. [24]" ], "subsections": [], "table": { "caption": "Pitfalls that should change the next diagnostic step. [4][18][19][20][24]", "columns": [ "Pitfall", "Why it misleads", "Correct next step" ], "rows": [ [ "Waiting for testing in shock", "Adrenal crisis requires immediate parenteral hydrocortisone. [22][24]", "Treat immediately; collect cortisol and ACTH only if treatment is not delayed. [19][22]" ], [ "Using cosyntropin to label disease as primary", "Chronic secondary disease can also produce a suboptimal response. [18][19]", "Classify with concurrent ACTH; add renin and aldosterone for a primary pattern. [19][23]" ], [ "Using a normal cosyntropin test to exclude recent central disease", "Acute secondary or tertiary adrenal insufficiency may retain adrenal responsiveness. [20]", "Consider endocrinology-supervised insulin tolerance or metyrapone testing when suspicion persists. [11][19]" ], [ "Ignoring corticosteroid exposure", "Systemic corticosteroids are associated with adrenal insufficiency; inhaled fluticasone has been associated with impaired adrenal response. [4][15]", "Reconstruct systemic, inhaled, and interacting drug exposure before assigning idiopathic central disease. [4][15]" ] ] } } ], "faq": [], "references": [ { "number": 1, "title": "invasive diagnostic test for patients with adrenal insufficiency using", "detail": "bmjopen.bmj.com", "url": "https://bmjopen.bmj.com/content/bmjopen/16/2/e112708.full.pdf", "authors": "bmjopen.bmj.com", "host": "bmjopen.bmj.com" }, { "number": 2, "title": "Consensus-based disease definitions for endocrine immune-related ...", "detail": "jitc.bmj.com", "url": "https://jitc.bmj.com/content/jitc/13/10/e011865.full.pdf", "authors": "jitc.bmj.com", "host": "jitc.bmj.com" }, { "number": 3, "title": "the STARLIT-3 study protocol | BMJ Open", "detail": "bmjopen.bmj.com", "url": "https://bmjopen.bmj.com/content/16/2/e112708", "authors": "bmjopen.bmj.com", "host": "bmjopen.bmj.com" }, { "number": 4, "title": "British Thoracic Society Guideline for bronchiectasis in adults - Thorax", "detail": "thorax.bmj.com", "url": "https://thorax.bmj.com/content/74/Suppl_1/1", "authors": "thorax.bmj.com", "host": "thorax.bmj.com" }, { "number": 5, "title": "The diagnosis and treatment of adrenal insufficiency during ...", "detail": "adc.bmj.com", "url": "https://adc.bmj.com/content/early/2016/04/15/archdischild-2015-308799?versioned=true", "authors": "adc.bmj.com", "host": "adc.bmj.com" }, { "number": 6, "title": "Hydrocortisone Dosing for Adrenal Insufficiency | NEJM Clinician", "detail": "clinician.nejm.org", "url": "https://clinician.nejm.org/hydrocortisone-dosing-adrenal-insufficiency-nejm-jw.NA42734", "authors": "clinician.nejm.org", "host": "clinician.nejm.org" }, { "number": 7, "title": "Nature Index Adrenal Insufficiency Diagnosis and Management", "detail": "www.nature.com", "url": "https://www.nature.com/nature-index/topics/l4/adrenal-insufficiency-diagnosis-and-management", "authors": "www.nature.com", "host": "www.nature.com" }, { "number": 8, "title": "Management of Primary Adrenal Insufficiency and Overt ...", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/10.1002/ccr3.71401", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com" }, { "number": 9, "title": "Adrenal Insufficiency During Treatment With Immune‐Checkpoint ...", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/pdf/10.1111/cen.70023", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com" }, { "number": 10, "title": "Diagnostic Accuracy of Basal Cortisol Level to Predict Adrenal Insufficiency in Cosyntropin Testing: Results from an Observational Cohort Study with 804 Patients", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S1530891X20358511", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com" }, { "number": 11, "title": "Diagnostic Predicament of Secondary Adrenal Insufficiency - ScienceDirect", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S1530891X20408171", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com" }, { "number": 12, "title": "ACTH Stimulation Test - an overview", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/topics/agricultural-and-biological-sciences/acth-stimulation-test", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com" }, { "number": 13, "title": "Secondary Adrenal Insufficiency: Recent Updates and New Directions for Diagnosis and Management", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S1530891X21012428", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com" }, { "number": 14, "title": "Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline", "detail": "academic.oup.com", "url": "https://academic.oup.com/jcem/article/101/2/364/2810222", "authors": "academic.oup.com", "host": "academic.oup.com" }, { "number": 15, "title": "Long‐term corticosteroid use, adrenal insufficiency and the need for ...", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/full/10.1111/joim.13273", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com" }, { "number": 16, "title": "Adrenal Tuberculosis Presenting as Adrenal Crisis: A Rare ...", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/10.1155/crie/9086526", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com" }, { "number": 17, "title": "Diagnosis and Treatment of Primary Adrenal Insufficiency", "detail": "www.ccjm.org", "url": "https://www.ccjm.org/lookup/external-ref?access_num=10.1210%2Fjc.2015-1710&link_type=DOI", "authors": "www.ccjm.org", "host": "www.ccjm.org" }, { "number": 18, "title": "Primary adrenal insufficiency in adults: When to suspect, how to ...", "detail": "www.ccjm.org", "url": "https://www.ccjm.org/content/91/9/553", "authors": "www.ccjm.org", "host": "www.ccjm.org" }, { "number": 19, "title": "[PDF] Abdominal pain without physical findings is not always without ...", "detail": "www.ccjm.org", "url": "https://www.ccjm.org/content/ccjom/91/9/local/complete-issue.pdf", "authors": "www.ccjm.org", "host": "www.ccjm.org" }, { "number": 20, "title": "A 71-year-old woman with shock and a high INR | Cleveland Clinic Journal of medicine", "detail": "www.ccjm.org", "url": "https://www.ccjm.org/content/85/4/303/tab-figures-data", "authors": "www.ccjm.org", "host": "www.ccjm.org" }, { "number": 21, "title": "Clinical Management of Adrenocortical Carcinoma - Endocrine Society", "detail": "www.endocrine.org", "url": "https://www.endocrine.org/-/media/endocrine/files/endo-annual-meetings/2012endoabstracts.html", "authors": "www.endocrine.org", "host": "www.endocrine.org" }, { "number": 22, "title": "Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline - PMC", "detail": "www.ncbi.nlm.nih.gov", "url": "https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4880116?term=%22J+Clin+Endocrinol+Metab%22%5Bjour%5D", "authors": "www.ncbi.nlm.nih.gov", "host": "www.ncbi.nlm.nih.gov" }, { "number": 23, "title": "Primary Adrenal Insufficiency Guideline Resources | Endocrine Society", "detail": "support.endocrine.org", "url": "https://support.endocrine.org/clinical-practice-guidelines/primary-adrenal-insufficiency", "authors": "support.endocrine.org", "host": "support.endocrine.org" }, { "number": 24, "title": "Adrenal insufficiency: identification and management - NCBI Bookshelf", "detail": "www.ncbi.nlm.nih.gov", "url": "https://www.ncbi.nlm.nih.gov/books/NBK609655", "authors": "www.ncbi.nlm.nih.gov", "host": "www.ncbi.nlm.nih.gov" } ], "editorialNote": "Prepared from cited clinical literature using Astra's research workflow. Verify recommendations against current guidance and patient-specific factors.", "citations": [ { "number": 1, "title": "invasive diagnostic test for patients with adrenal insufficiency using", "detail": "bmjopen.bmj.com", "url": "https://bmjopen.bmj.com/content/bmjopen/16/2/e112708.full.pdf", "authors": "bmjopen.bmj.com", "host": "bmjopen.bmj.com", "snippet": "Endocrinol (Oxf) 2014;80:376–83. 21 National Institute for Health and Care Excellence (NICE). Adrenal insufficiency: evidence review D - Diagnostic tests and diagnostic thresholds for referral. NICE guideline [NG243]. 2024. Available: tests-and-diagnostic-thresholds-for-referral-pdf-13494270784 22 ", "score": 0.5417246 }, { "number": 2, "title": "Consensus-based disease definitions for endocrine immune-related ...", "detail": "jitc.bmj.com", "url": "https://jitc.bmj.com/content/jitc/13/10/e011865.full.pdf", "authors": "jitc.bmj.com", "host": "jitc.bmj.com", "snippet": "Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. Corticotropin tests for hypothalamic- Metab", "score": 0.5335682 }, { "number": 3, "title": "the STARLIT-3 study protocol | BMJ Open", "detail": "bmjopen.bmj.com", "url": "https://bmjopen.bmj.com/content/16/2/e112708", "authors": "bmjopen.bmj.com", "host": "bmjopen.bmj.com", "snippet": "Cosyntropin as a diagnostic agent in the screening of patients for adrenocortical insufficiency.", "score": 0.43741554 }, { "number": 4, "title": "British Thoracic Society Guideline for bronchiectasis in adults - Thorax", "detail": "thorax.bmj.com", "url": "https://thorax.bmj.com/content/74/Suppl_1/1", "authors": "thorax.bmj.com", "host": "thorax.bmj.com", "snippet": "Corticosteroid responses in patients with bronchiectasis, of whom a high proportion were taking inhaled fluticasone, were found to be impaired in a cross-sectional analysis.176 Inhaled fluticasone treatment appeared to double the risk. Adrenal insufficiency was associated with poorer quality of life", "score": 0.28750315 }, { "number": 5, "title": "The diagnosis and treatment of adrenal insufficiency during ...", "detail": "adc.bmj.com", "url": "https://adc.bmj.com/content/early/2016/04/15/archdischild-2015-308799?versioned=true", "authors": "adc.bmj.com", "host": "adc.bmj.com", "snippet": "The diagnosis and treatment of adrenal insufficiency in childhood and adolescence poses a number of challenges. Clinical features of chronic adrenal insufficiency are vague and non-specific, and mimic many other causes of chronic ill health. A range of diagnostic tests are available for the assessme", "score": 0.5360463 }, { "number": 6, "title": "Hydrocortisone Dosing for Adrenal Insufficiency | NEJM Clinician", "detail": "clinician.nejm.org", "url": "https://clinician.nejm.org/hydrocortisone-dosing-adrenal-insufficiency-nejm-jw.NA42734", "authors": "clinician.nejm.org", "host": "clinician.nejm.org", "snippet": "###### Topics\n\nNo universally accepted glucocorticoid replacement dose exists for patients with adrenal insufficiency. When hydrocortisone is used, divided doses often are given to mimic natural diurnal variation (higher dose early, lower dose later). In this double-blind crossover study, researcher", "score": 0.4611872 }, { "number": 7, "title": "Nature Index Adrenal Insufficiency Diagnosis and Management", "detail": "www.nature.com", "url": "https://www.nature.com/nature-index/topics/l4/adrenal-insufficiency-diagnosis-and-management", "authors": "www.nature.com", "host": "www.nature.com", "snippet": "Title: Nature Index Adrenal Insufficiency Diagnosis and Management\nView the latest institution rankings. View the latest Country/territory rankings. # Adrenal Insufficiency Diagnosis and Management. Adrenal insufficiency arises when the adrenal cortex fails to produce adequate glucocorticoids, most ", "score": 0.7959917 }, { "number": 8, "title": "Management of Primary Adrenal Insufficiency and Overt ...", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/10.1002/ccr3.71401", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com", "snippet": "10 Primary Adrenal Insufficiency Guideline Resources (Endocrine Society, 2025), https://www.endocrine.org/clinical-practice-guidelines", "score": 0.69845337 }, { "number": 9, "title": "Adrenal Insufficiency During Treatment With Immune‐Checkpoint ...", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/pdf/10.1111/cen.70023", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com", "snippet": "Endocrine Society guidelines (500 nmol/L) Morning SC is a reliable tool for the screening of ICI‐related AI;", "score": 0.39487803 }, { "number": 10, "title": "Diagnostic Accuracy of Basal Cortisol Level to Predict Adrenal Insufficiency in Cosyntropin Testing: Results from an Observational Cohort Study with 804 Patients", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S1530891X20358511", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com", "snippet": "Diagnostic Accuracy of Basal Cortisol Level to Predict Adrenal Insufficiency in Cosyntropin Testing: Results from an Observational Cohort Study with 804 Patients. **_Objective:_**Adrenocorticotrophic hormone (ACTH) stimulation testing is the current standard for assessing primary and secondary adren", "score": 0.98302 }, { "number": 11, "title": "Diagnostic Predicament of Secondary Adrenal Insufficiency - ScienceDirect", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S1530891X20408171", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com", "snippet": "On testing by the insulin tolerance test (ITT) in the first patient and the overnight metyrapone test (OMT) in the second patient, secondary AI was diagnosed.", "score": 0.97981 }, { "number": 12, "title": "ACTH Stimulation Test - an overview", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/topics/agricultural-and-biological-sciences/acth-stimulation-test", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com", "snippet": "The ACTH stimulation test is defined as a diagnostic procedure used to assess adrenocortical reserve capacity by measuring cortisol levels before and after the administration of synthetic ACTH, particularly in cases of suspected primary or secondary adrenocortical insufficiency. AI generated definit", "score": 0.97529 }, { "number": 13, "title": "Secondary Adrenal Insufficiency: Recent Updates and New Directions for Diagnosis and Management", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S1530891X21012428", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com", "snippet": "In this review, we discuss the etiology, epidemiology, and clinical presentation of secondary adrenal insufficiency and focus on the diagnostic and management challenges. We also review the management of selected special populations of patients and discuss patient-important outcomes associated with ", "score": 0.96889 }, { "number": 14, "title": "Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline", "detail": "academic.oup.com", "url": "https://academic.oup.com/jcem/article/101/2/364/2810222", "authors": "academic.oup.com", "host": "academic.oup.com", "snippet": "We recommend diagnostic tests for the exclusion of primary adrenal insufficiency in all patients with indicative clinical symptoms or signs. 1.1 We recommend diagnostic testing to exclude primary adrenal insufficiency (PAI) in acutely ill patients with otherwise unexplained symptoms or signs suggest", "score": 0.7982658 }, { "number": 15, "title": "Long‐term corticosteroid use, adrenal insufficiency and the need for ...", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/full/10.1111/joim.13273", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com", "snippet": "A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy.", "score": 0.49450764 }, { "number": 16, "title": "Adrenal Tuberculosis Presenting as Adrenal Crisis: A Rare ...", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/10.1155/crie/9086526", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com", "snippet": "Primary adrenal insufficiency (AI) is a rare endocrine disease. It is characterized by a primary adrenal cortical insufficiency, which is", "score": 0.5792344 }, { "number": 17, "title": "Diagnosis and Treatment of Primary Adrenal Insufficiency", "detail": "www.ccjm.org", "url": "https://www.ccjm.org/lookup/external-ref?access_num=10.1210%2Fjc.2015-1710&link_type=DOI", "authors": "www.ccjm.org", "host": "www.ccjm.org", "snippet": "This clinical practice guideline addresses the diagnosis and treatment of primary adrenal insufficiency.Participants:. a cosyntropin stimulation test may be", "score": 0.72559077 }, { "number": 18, "title": "Primary adrenal insufficiency in adults: When to suspect, how to ...", "detail": "www.ccjm.org", "url": "https://www.ccjm.org/content/91/9/553", "authors": "www.ccjm.org", "host": "www.ccjm.org", "snippet": "## DISCLOSURES\n\nThe authors report no relevant financial relationships which, in the context of their contributions, could be perceived as a potential conflict of interest.\n\n Copyright © 2024 The Cleveland Clinic Foundation. All Rights Reserved.\n\n## REFERENCES\n\n1. 1\n\n ↵\n\n Bornstein SR, Allolio B", "score": 0.62906903 }, { "number": 19, "title": "[PDF] Abdominal pain without physical findings is not always without ...", "detail": "www.ccjm.org", "url": "https://www.ccjm.org/content/ccjom/91/9/local/complete-issue.pdf", "authors": "www.ccjm.org", "host": "www.ccjm.org", "snippet": "CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 91 • NUMBER 9 SEPTEMBER 2024 PRIMARY ADRENAL INSUFFICIENCY disease; even in secondary disease the adrenal gland has a slow, suboptimal response to synthetic exoge-nous adrenocorticotropic hormone due to a chronic lack of endogenous stimulus. The adrenocort", "score": 0.59401023 }, { "number": 20, "title": "A 71-year-old woman with shock and a high INR | Cleveland Clinic Journal of medicine", "detail": "www.ccjm.org", "url": "https://www.ccjm.org/content/85/4/303/tab-figures-data", "authors": "www.ccjm.org", "host": "www.ccjm.org", "snippet": "The test can be done using a high or low dose of cosyntropin. The Endocrine Society’s 2016 guidelines recommend the high dose (250 μg) for most patients.10 The standard high-dose stimulation test can be done at any time during the day.26 If the cosyntropin is injected intravenously, any value higher", "score": 0.54608524 }, { "number": 21, "title": "Clinical Management of Adrenocortical Carcinoma - Endocrine Society", "detail": "www.endocrine.org", "url": "https://www.endocrine.org/-/media/endocrine/files/endo-annual-meetings/2012endoabstracts.html", "authors": "www.endocrine.org", "host": "www.endocrine.org", "snippet": "MEET-THE-PROFESSOR: CLINICAL - Clinical Management of Adrenocortical Carcinoma (1:00 PM - 1:45 PM). MEET-THE-PROFESSOR: CLINICAL - Evaluation of Premature Adrenarche (1:00 PM - 1:45 PM). MEET-THE-PROFESSOR: CLINICAL - Pubertal Disruption in Chronic Inflammatory Disease (1:00 PM - 1:45 PM). MEET-THE-", "score": 0.96398 }, { "number": 22, "title": "Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline - PMC", "detail": "www.ncbi.nlm.nih.gov", "url": "https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4880116?term=%22J+Clin+Endocrinol+Metab%22%5Bjour%5D", "authors": "www.ncbi.nlm.nih.gov", "host": "www.ncbi.nlm.nih.gov", "snippet": "Title: Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline - PMC\n1.1 We recommend diagnostic testing to exclude primary adrenal insufficiency (PAI) in acutely ill patients with otherwise unexplained symptoms or signs suggestive of PAI (volume de", "score": 0.783542 }, { "number": 23, "title": "Primary Adrenal Insufficiency Guideline Resources | Endocrine Society", "detail": "support.endocrine.org", "url": "https://support.endocrine.org/clinical-practice-guidelines/primary-adrenal-insufficiency", "authors": "support.endocrine.org", "host": "support.endocrine.org", "snippet": "Title: Primary Adrenal Insufficiency Guideline Resources | Endocrine Society\n###### Learning. * Claim credits* Plan your learning* Browse journals and articles* View sessions recordings. ###### Membership. * Renew membership* Submit Your Science!* Find other members* Become a member leader. ###### C", "score": 0.769306 }, { "number": 24, "title": "Adrenal insufficiency: identification and management - NCBI Bookshelf", "detail": "www.ncbi.nlm.nih.gov", "url": "https://www.ncbi.nlm.nih.gov/books/NBK609655", "authors": "www.ncbi.nlm.nih.gov", "host": "www.ncbi.nlm.nih.gov", "snippet": "Admit the person to hospital during periods of physiological stress if they are unable to absorb oral glucocorticoids, for example, during prolonged diarrhoea and vomiting. Give 100 mg intramuscular or intravenous hydrocortisone. See recommendation 1.7.1\non emergency management of adrenal crisis.\n\nF", "score": 0.68874115 } ], "publishedAt": "2026-09-15T22:07:07.675647+00:00", "updatedAt": "2026-09-15T22:07:07.675647+00:00", "readingMinutes": 5, "slug": "adrenal-insufficiency-diagnostic-testing" }