What are the findings from the ACTH stimulation test?
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Posted Mon, 20 Jan 2014 in Thyroid Problem and Hormonal Problems
Answered by Dr. Shehzad Topiwala 1 hour later
Brief Answer: Endocrine Detailed Answer: At face value, the results on the ACTH stimulation test suggest the presence of adrenal insufficiency ie low cortisol in the blood, likely from a deficiency in production by the adrenal glands. Hence the endocrinologist who saw her was justified in starting hydrocortisone and fludrocortisone. Unfortunately she does not seem to have responded, which then makes one reassess the diagnosis. The numbers on the ACTH stimulation test are impressive for low values. However, there are a couple comments worth making here. 1 Sometimes the blood tests for cortisol can be misleading when the CBG (Cortisol Binding Globulin) is low. This implies that the individual does not really have a low cortisol problem. It is a rare condition but in this instance worth checking for as a lab test for CBG. It can be done randomly at any time of the day or night and does not require fasting. It can be done even if she is already on treatment with hydrocortisone and fludrocortisone. 2 Sometimes pain meds of the opioid type can cause adrenal insufficiency by dampening the pituitary signal to the adrenal glands. So if she does have true adrenal deficiency, then we have a potential cause for it in her case 3 Typically, when a person has significant adrenal deficiency as suggested by the numbers on the test your mother-in-law had, the symptoms are remarkable such as low blood pressure and fatigue. This typically responds dramatically to the right treatment. Perhaps another systematic evaluation is in order. Some tests will require her to off hydrocortisone for at least 24 hours such as a 8 am cortisol repeat check. If a blood sample is taken, it will be useful to run the following tests on the same sample: 1 ACTH 2 TSH 3 Free T4 4 Prolactin 5 FSH 6 LH 7 anti 21 hydroxylase antibody and as mentioned above 8 CBG 9 Cortisol at 8 am along with 10 CBC with differential 11 CMP
Follow-up: What are the findings from the ACTH stimulation test? 10 hours later
Thank you very much for your reply. I would like to add some additional details that I am now aware of. The first thing is that on Nov 26th she had an 11:30 am NON fasting cortisol level of 24.2. Then on Dec 6th she had a fasting morning cortisol test that was 2.0. This test result is why she had the ACTH test on Dec 19th that I referenced in my first question (1.8,6.9,9.3). She started taking the Percocet after her Gall Bladder surgery on Nov 20th. Her current dosage seems quite small, she takes half of a 5/325 tablet two or three times a day (along with half of a xanax .5). Would that be a sufficient dosage to cause adrenal insufficiency?
Answered by Dr. Shehzad Topiwala 14 hours later
Brief Answer: Follow up Detailed Answer: I have noted your comments above. The aforementioned tests will corroborate the diagnosis. Whether the given dose of Percocet is responsible is difficult to categorically state. However a personal assessment by an endocrinologist allows physical and lab findings to be put together in perspective, in order to make the the final call