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Diagnosing adrenal insufficiency using ACTH stimulation test

Brian Lipworth, Rory Chan, Chris RuiWen Kuo
European Respiratory Journal 2020 56: 2001478; DOI: 10.1183/13993003.01478-2020
Brian Lipworth
Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee Scotland, UK
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  • For correspondence: b.j.lipworth@dundee.ac.uk
Rory Chan
Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee Scotland, UK
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Chris RuiWen Kuo
Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee Scotland, UK
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Abstract

Low dose ACTH stimulation test is more likely to detect adrenal insuffiency in patients being weaned off oral corticosteroids https://bit.ly/2XsMA3i

To the Editor:

We read with interest the real-world data of Nanzer et al. [1], looking at adrenal insufficiency (AI) in severe asthma patients taking oral corticosteroid-sparing anti-interleukin (IL)-5 therapy. They reported that 43% of patients apparently failed a short adrenocorticotropic hormone (ACTH) stimulation test associated with a median baseline morning serum cortisol of 86 nmol·L−1 and a median prednisolone dose of 5 mg. We would be interested to know the mean cortisol level after ACTH, as well as the percentage of patients who failed to achieve a post-ACTH level of 500 nmol·L−1 which is the accepted cut-off for impaired response [2, 3]. Pointedly they used a pharmacological 250 µg dose of ACTH instead of the more physiological 0.5–1 µg dose [3, 4]. We suggest that using the correct ACTH dose in conjunction with a 500 nmol·L−1 cortisol cut off would be accompanied by a higher proportion of patients designated with AI. Finally, we also note that their patients were taking high-dose inhaled corticosteroid at a fluticasone propionate equivalent dose of 1 mg·day−1. In this regard, 1 mg of inhaled fluticasone propionate exhibits a cortisol suppressive potency equivalent to 8.5 mg of oral prednisolone [5]. Hence, while it might have been possible to wean the prednisolone dose to 5 mg on anti-IL-5, in reality patients were likely to have been exposed to a much higher total systemic corticosteroid burden.

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Footnotes

  • Conflict of interest: B. Lipworth reports equipment from GSK , grants, personal fees for advisory board work, consultancy and lectures, and non-financial support for meeting attendance from AstraZeneca and Teva, personal fees for consultancy from Lupin, Glenmark, Vectura, Dr Reddy and Sandoz, during the conduct of the study; grants, personal fees for consultancy and lectures, and non-financial support for meeting attendance from Boehringer Ingelheim, grants and personal fees for advisory board work, consultancy and lectures from Mylan, grants and personal fees for advisory board work and consultancy from Sanofi Regeneron, outside the submitted work; and has a family member who is an employee of AstraZeneca.

  • Conflict of interest: R. Chan has nothing to disclose.

  • Conflict of interest: C.R.W. Kuo reports personal fees for meeting attendance from AstraZeneca, personal fees for meeting attendance and lectures from Chiesi, personal fees for advisory board work from Circassia, outside the submitted work.

  • Received April 29, 2020.
  • Accepted May 19, 2020.
  • Copyright ©ERS 2020
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References

  1. ↵
    1. Nanzer AM,
    2. Chowdhury A,
    3. Raheem A, et al.
    Prevalence and recovery of adrenal insufficiency in steroid-dependent asthma patients receiving biologic therapy. Eur Respir J 2020; 56: 1902273.
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Wilson AM,
    2. McFarlane LC,
    3. Lipworth BJ
    . Effects of low and high doses of inhaled flunisolide and triamcinolone acetonide on basal and dynamic measures of adrenocortical activity in healthy volunteers. J Clin Endocrinol Metab 1998; 83: 922–925. doi:10.1210/jcem.83.3.4637
    OpenUrlCrossRefPubMedWeb of Science
  3. ↵
    1. Broide J,
    2. Soferman R,
    3. Kivity S, et al.
    Low-dose adrenocorticotropin test reveals impaired adrenal function in patients taking inhaled corticosteroids. J Clin Endocrinol Metab 1995; 80: 1243–1246.
    OpenUrlCrossRefPubMedWeb of Science
  4. ↵
    1. Rasmuson S,
    2. Olsson T,
    3. Hagg E
    . A low dose ACTH test to assess the function of the hypothalamic-pituitary-adrenal axis. Clin Endocrinol (Oxf) 1996; 44: 151–156. doi:10.1046/j.1365-2265.1996.600482.x
    OpenUrlCrossRefPubMed
  5. ↵
    1. Wilson AM,
    2. Lipworth BJ
    . Short-term dose-response relationships for the relative systemic effects of oral prednisolone and inhaled fluticasone in asthmatic adults. Br J Clin Pharmacol 1999; 48: 579–585. doi:10.1046/j.1365-2125.1999.00058.x
    OpenUrlCrossRefPubMedWeb of Science
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Diagnosing adrenal insufficiency using ACTH stimulation test
Brian Lipworth, Rory Chan, Chris RuiWen Kuo
European Respiratory Journal Aug 2020, 56 (2) 2001478; DOI: 10.1183/13993003.01478-2020

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Diagnosing adrenal insufficiency using ACTH stimulation test
Brian Lipworth, Rory Chan, Chris RuiWen Kuo
European Respiratory Journal Aug 2020, 56 (2) 2001478; DOI: 10.1183/13993003.01478-2020
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