Dexamethasone

Suppression test

CRH stimulation test

ACTH-stimulation
tests
(Cosyntropyn aka
Cortrosyn)
Metyrapone test

Insulin induced

- For suspected over activity of the adrenals

- Dexamethasone is a glucocorticoid
Testing for cause of Cushings Syndrome
- High free cortisol on 24hr urine analysis and high midnight salivary cortisol
- Low dose dexamthasome testing: No suppression if Cushings Syndrome
- Next measure serum ACTH: if low iatrogenic Cushings or adrenal cortisol secreting tumor
- If serum ACTH is high need to do a high dose dexameth test to determine the source of
the ACTH secretion that is causing the cushings (also can do CRH stim test for this step)
- If high dose dexameth causes suppression of cortisol levels Cushings disease
- If high dose dexamth does not cause suppression of cortisol ectopic ACTH secretion
Distinguishes between ACTH dependent Cushings Syndrome caused by ectopic ACTH secretion vs
by Cushings Disease
- If ACTH and cortisol levels rise with CRH administration Cushings Disease
- If ACTH and cortisol levels do not rise with CRH admin ectopic ACTH secretion (because
the high cortisol due to ectopic ACTH production is feeding back to inhibit pituitary ACTH
secretion so it unresponsive to the CRH)
For suspected underactivity of the adrenals to differentiate primary (cause is adrenal) and
secondary (cause is hypothal/pit) adrenal insufficiency
Cortisol should rise with ACTH administration:
- Primary insufficiency (Addisons) cortisol will not rise much
- Secondary insufficiency cortisol will rise substantially (if the adrenals lack ACTH stim for
enough time, cortisol production may be blunted bc of adrenal atrophy)
- Metyrapone blocks conversion of 11-deocycortisol cortisol by inhibiting 11betahydroxylase this increases ACTH secretion b/c low cortisol production
Can be used to diagnose adrenal insufficiency:
- If intact HPA axis, CRH+ACTH levels should rise in response to falling cortisol levels and this
should cause an increase in steroid precursors in the pathway (11-deoxycortisol aka DOC)
- If ACTH rises but DOC levels do not rise: suggestive of primary adrenal
insufficiency
- If neither DOC or ACTH rise: suggestive of secondary adrenal insuf: impaired HPA
axis at pit or hypothalamus
*most pituitary microadenomas causing cushings will show an increase in ACTH secretion in
response to metyrapone whereas most ectopic ACTH producing tumors will not
Measures integrity of HPA axis

hypoglycemia
response

Give insulin to induce hypoglycemia ACTH levels should rise to cause an increase in
cortisol
***also should get a rise in GH, glucagon, epinephrine etc. (counter regulatory hormones)