Indications

Possible SE/
Contraindications

Rationale

Methods of Measurement

Interpretation

Precaution

HYPOTHALAMIC PITUITARY FUNCTION TEST

Rapid ACTH
Stimulation Test

Insulin
hypoglycemia test

Primary vs Secondary
Adrenal Insufficiency

Assessment of
ACTH/Cortisol and GH
reserve

Hypersenstivity to
ACTH
Pregnancy

Epilepsy or
unexplained
blackouts
Ischemic Heart
Disease or CVD
Severe long
standing
hypoadrenalism
Glycogen storage
diseases

ACTH stimulation
should lead to increase
release of cortisol in the
adrenals

The stress of insulin

induced hypoglycemia
triggers the release of
GH and ACTH from the
pituitary gland in
normal subjects
GH response is
measured directly;
cortisol is measured as
the indicator of ACTH
secretion

Administer synthetic ACTH

(cosyntropin) 250 g IV or
IM. The test may be
performed at any time of
the day or night and dont
require fasting. Obtain
samples for plasma
cortisol at 0, 15, 30 and 60
min
Give nothing by mouth
after midnight. Start an IV
infusion with NSS. Regular
insulin is given IV in a dose
sufficient to cause
adequate hypoglycemia
(blood glucose <40 mg/dl)
Usual dose: 0.15 U/kg
Cushings and acromegaly:
0.3 U/kg

Secondary Adrenal Insufficiency

Plasma cortisol level > 500 nmol/

L (preferably 550 nmol/L)
Primary Adrenal Insufficiency

Plasma cortisol level < 500

nmol/L

Normal response:
Venous plasma glucose concentration
fallen to <2.2 mmol/L (evidence of
sufficient stress)
Cortisol deficiency:
An increment <220 nmol/L
Peak level < 550 nmol/L

ECG must be
normal
Serum cortisol
must be >100
nmol/L
Normal serum T4

ACTH deficiency : < 22 pmol/L

If adequate hypoglycemia wasnt achieved
cortisol or GH deficiency cant be
diagnosed
GH deficiency
<10 mU/L

Metyrapone Test

Glucagon

To diagnose adrenal
insufficiency and to
assess pituitary-adrenal
reserve

Assessment of ACTH/

GI upset may occur

Adrenal
insufficiency may
occur
Sick people
Primary adrenal
insufficiency

Recent or

Metyrapone blocks
cortisol synthesis by
inhibiting the 1 1 B
hydroxylase enzyme
that converts 1 1
deoxycortisol to
cortisol. This stimulates
ACTH
secretion, which in turn
increases the secretion
and plasma levels
of 1 1-deoxycortisol
Glucagon stimulates GH

Take Metyrapone (30

mg/kg orally at midnight)

Partial GH deficiency
10-20 mU/L
Normal Response:
plasma 11-deoxycortisol level > 7 mg/dL
plasma ACTH level > 1 00 pg/mL
plasma cortisol: <5 mg/dL
Subnormal response: Adrenal
Insufficiency
Normal response: accurately predicts
normal stress responsiveness of the
hypothalamic-pituitary axis \

The patient should be

Normal response

Serum cortisol >

stimulation test

TRH Test

cortisol and GH reserve

when ITT
contraindicated

intercurrent illness
Severe cortisol
deficiency
Glycogen storage
diseases
Patients who havent
eaten for 48 hours

Assessment of function
of pituitary to secrete
TSH

release
A safer test than insulin
hypoglycemic test in
young children and
infants as it doesnt
usually cause the same
degree of hypoglycemia
as is induced during an
ITT

fasting after midnight.

Give glucagon 1 mg IM

Protirelin should
increase the levels of
TSH release

Fasting is not required, but

since nausea may occur, it
is preferred. Give
protirelin, 500 g IV over
15-30 sec. The patient
should be kept supine,
since slight hypertension
or hypotension may occur.

Differentiate primary to
secondary
hypothyroidism

GnRH test

CRH Test

Hypogonadotrophic
hypogonadism

assess ACTH secretory

dynamics.

Administration of GnRH
causes a prompt
increase in plasma LH
and a lesser and slower
increase in FSH.

Flushing often
occurs. Transient
tachycardia and

However, in most
patients, the GnRH test
provides no more
useful information than
is obtained by
measurement of basal
gonadotropin and
gonadal steroid levels.
Thus, this test is
uncommonly
performed.
Stimulates directly the
pituitary corticotrophs
to release ACTH

Plasma glucose: usually rises to peak

around 90 min and then falls
Cortisol: rises by >200 nmol/L to above
550 nmol/L
GH: rises to > 20mU/L

Blood for determination of

plasma TSH and PRL is
obtained at 0, 30 and 60
min
The patient should be at
rest but need not be
fasting. Give GnRH, 100 g
IV over 15 sec
Blood samples for LH and
FSH determinations are
taken at 0, 30 and 60 min

CRH is given IV as a bolus

injection

Interpretation:
Peak GH: 120 min
Peak GH response < 10mU/L- GH
deficiency
Responses of 10-20 mU/L: Partial GH
deficiency
Low TSH
< 6 mU/L in women and men aged <49
< 2 mU/L in men aged 70-79

This response is dependent on sex and the

time of the menstrual cycle.
Increase of LH of 1.3-2.6 g/L (12-23 IU/L)
is considered normal. FSH usually respond
more slowly and less markedly

The peak cortisol response occurs at 30-60

min: > 10g/dL

100 nmol/L
Serum T4 must be
normal

hypotension have
also been reported

Blood samples for ACTH

and cortisol are taken at
0,15, 30 and 60 min

Primary adrenal insufficiency

have elevated basal ACTH levels
and exaggerated ACTH
responses to CRH.
Secondary adrenal insufficiency
results in an absent ACTH
response to CRH in patients
with primary corticotroph
destruction
Hypothalamic dysfunction
there is a prolonged and
augmented ACTH response to
CRH with a delayed pek
Because of overlap between the responses
of normal individuals and those with
partial secondary adrenal insufficiency, the
CRH test is less useful than the procedures
described above

CORTISOL FUNCTION TEST

Overnight
Dexamethasone
suppression test

used to establish the

presence of Cushing
syndrome regardless of
its cause.
Useful initial screening
for Cushings syndrome

24 h Urine free
Cortisol

Dexamethasone, a potent
glucocorticoid, normally
suppresses
pituitary ACTH release
with a resulting fall in
plasma and urine
cortisol, thus assessing
feedback inhibition of the
HPA axis. In
Cushing syndrome, this
mechanism is abnormal,
and steroid
secretion fails to be
suppressed in the normal
way. Dexamethasone
in the doses used does not
interfere with the
measurement of
plasma and urinary
cortisol.

The overnight 1 -mg

dexamethasone
suppression test is
commonly used as a
screening test for Cushing
syndrome.
Dexamethasone, 1 mg
orally, is given as a single
dose at 11 :00 PM, and the
following morning a
plasma sample is obtained
for cortisol determination

Normal subjects will have a 9 am

cortisol of < 50 nmol/L
Supression: No Cushings Syndrome
No Supression:
Following are the causes for serum
cortisol level to be > 50 nmol/L (failure
to suppress) following
overnight dexamethasone test.
1. Cushings syndrome
2. Stress
3. Obesity
4. Oral contraceptive use
5. Pregnancy
6. Estrogen therapy
7. Alcoholism
8. Acute or chronic illness

UFC may not identify patients with mild

hypercortisolism and therefore UFC
cannot be

considered a universal single screening

test for
the detection of Cushings syndrome

Low Dose
Dexamethasone
Suppression Test

Establish the presence of

Cushing syndrome
regardless of its cause

Normal response
Basal serum cortisol is in
the normal resting am
range at 9.00 (170-700
nmol/L)
After 48 hours serum
cortisol is suppressed to <
50 nmol/L

High Dose
Dexamethasone
suppression test

High-dose dexamethasone
suppression testing has
historically been used to
differentiate Cushing
disease (pituitary ACTH
hypersecretion) from
ectopic ACTH and adrenal
tumors.
This rationale has been
based on the fact that in
some patients with
Cushing disease, the HPA
axis is suppressible with
supraphysiologic doses of
glucocorticoids, whereas
cortisol secretion is

Draw a sample of blood at

9.00 am on day 0 for
serum cortisol.
Give dexamethasone 0.5
mg orally
strictly 6-hourly at 9.00,
15.00, 21.00 and 3.00 (9
am, 3pm, 9 pm and 3 am)
for 48 hours, commencing
immediately after the
basal sample.

Give 8 mg dexamethasone

This test is useful in

pregnancy
Patients on oral contraceptive
treatment or estrogens
A serum cortisol < 50 nmol/L after 48
hours excludes Cushings syndrome
unless clinical suspicion is very high
Nonsuppression with low dose
dexamethasone in the absence of
Cushings syndrome
- Severe endogenous depression.
Patients may have an abnormal
circadian rhythm but show normal
cortisol response to an ITT.
- Alcoholism(Alcoholic psudoCushings). Rapidly
reverses on stopping drinking
- Severe stressful illness /infection
- Oestrogen therapy Pregnancy,
Oral contraceptives due to high
globulin binding
proteins
- Corticosteroid therapy
Prednisolone & hydrocortisone
cross react in the cortisol assay
Supression with 8 mg test:
Cushings Disease
No suppression with Low ACTH
Adrenal tumor
No suppression with normal or very
elevated ACTH
Ectopic ACTH Syndrome
Suppression with Normal to Elevated
ACTH
Cushings Disease

Care in DM and
active peptic
ulceration

autonomous in patients
with adrenal tumors and in
most patients with the
ectopic ACTH syndrome
EVALUATION OF GH FUNCTION
Oral Glucose
Tolerance Test

Diagnosis of
acromegaly,
starvation, proteincalorie malnutrition

None
S/E: Nausea

Increase in glucose
should inhibit GH
release from the
anterior pituitary gland

The patient should be

fasting after midnight; give
glucose, 75-100 g orally.
GH and glucose should be
determined at 0 , 30, 60
min after glucose
administration

GH excess
- Radioimmnoassay: GH > 1 mcg/L
- Immunoradiometric assay: GH > 0.3
mcg/L

Cases with known

diabetes
A basal blood sugar
must be checked