Autoimmune polyglandular syndromes (APS) – type 1 and type 2
Some evidence that tds hydrocortisone is better than bd
Latest literature suggesting starting dose of 15mg/24hrs.
Most suggest 20-25mg/24hrs
No optimum test.
Respond quickly to cortisol, so no time period that you could count as normal
Hydrocortisone doesn’t have a smooth release so what are we really checking
24 hour urine cortisol
To check if they are taking it
Blood Pressure - postural
Plasma Renin (best measure of vol. status)
On the Horizon
Delayed release hydrocortisone
Slow release hydrocortisone
Treatment in Surgery
No clinical evidence
Larger doses traditionally given generally not needed.
Amounts should correlate to physiological increases in cortisol according to degree of stress.
Over-treatment may have wound healing consequences
Treatment in surgery
Is there a good screening test?
Is a baseline cortisol of value?
Is a morning cortisol a good screening test?
Hagg E, Asplund K, Lithner F. Value of basal plasma cortisol assays in the assessment of pituitary-adrenal insufficiency. Clin Endocrinol (Oxf) 1987; 26: 221–26.
Lee MT, Won JG, Lee TI, Yang HJ, Lin HD, Tang KT. The relationship between morning serum cortisol and the short ACTH test in the evaluation of adrenal insufficiency. Zhonghua Yi Xue Za Zhi (Taipei). 2002 Dec;65(12):580-7.
Both suggest that a cutoff of 300nmol/l rules out Addison’s
Our results over the past year
220 SST’s over the past year
18 results consistent with adrenal insufficiency
Everyone with a baseline cortisol >300 had a normal SST
Synacthen Tests for Ali Chakera.xls 18 202 21.9 NNV 88.9 Specificity 73 16 57 Negative 98.6 PPV 71.8 Sensitivity 147 2 145 Positive Test > 250 No Yes Normal Adrenals 18 202 16.7 NNV 100.0 Specificity 108 18 90 Negative 100.0 PPV 55.4 Sensitivity 112 0 112 Positive Test > 300 No Yes Normal Adrenals
Our results for the past 3 years
648 SST’s over the past year
60 results consistent with adrenal insufficiency = 53 patients
All bar one patient with a baseline cortisol >350 had a normal SST
3 years of synacthen results.xls 57 591 15.0 NNV 98.2 Specificity 374 56 318 Negative 99.6 PPV 46.2 Sensitivity 274 1 273 Positive Test > 350 No Yes Normal Adrenals 58 590 12.8 NNV 98.3 Specificity 445 57 388 Negative 99.5 PPV 34.2 Sensitivity 203 1 202 Positive Test > 400 No Yes Normal Adrenals
Addison’s disease needs a high index of suspicion.
There is no clear biochemical marker of adequate treatment.
There is no clear cut-off in terms of baseline cortisol – but perhaps GP’s could consider SST’s in primary care