QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Résumé Extracto Full Text PDF Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Articles Ahead of Print [Order Reprint] Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kozyra, E. F Articles by Burry, L. D Search for Related Content PubMed PubMed Citation Articles by Kozyra, E. F Articles by Burry, L. D

CRITICAL CARE

Can 1 µg of Cosyntropin Be Used to Evaluate Adrenal Insufficiency in Critically Ill Patients?

at time of writing, on clinical placement in the Medical-Surgical ICU, Mount Sinai Hospital, Toronto, Ontario, Canada; now, Clinical Pharmacy Specialist–Nephrology, Health Care Corporation of St. John's; Assistant Professor, School of Pharmacy, Memorial University of Newfoundland, St. John's, Newfoundland, Canada

Randy S Wax, MD FRCPC

Critical Care Physician, Department of Medicine, Mount Sinai Hospital; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

Lisa D Burry, BScPharm PharmD FCCP

Critical Care Specialist, Surgical Team Leader, Education Coordinator, Department of Pharmacy, Mount Sinai Hospital

Reprints: Dr. Burry, Department of Pharmacy, Rm. 1506, Mount Sinai Hospital, 600 University Ave., Toronto, Ontario M5G 1X5, Canada, fax 416/586-8353, lburry{at}mtsinai.on.ca

OBJECTIVE: To evaluate the utility of cosyntropin 1 µg in assessing adrenal function in critically ill patients.

DATA SOURCES: A computerized literature search using MEDLINE, EMBASE, International Pharmaceutical Abstracts, and the Cochrane Database (1966–August 2004) was undertaken for trials evaluating cosyntropin 1 µg using the following search terms: adrenocorticotropin-releasing hormone (ACTH), cosyntropin, adrenal insufficiency, cortisol, corticosteroids, glucocorticoids, sepsis, septic shock, diagnosis, critically ill, intensive care, and critical care.

STUDY SELECTION AND DATA SYNTHESIS: Identifying patients with sepsis with relative adrenal insufficiency (AI) using cosyntropin testing may identify those likely to benefit from corticosteroids. The results of 5 heterogeneous studies in non–intensive care unit (ICU) patients suggest that both 1 µg and 250 µg of cosyntropin stimulate similar cortisol responses and that testing using both doses correlates well with results from insulin tolerance testing. Some data from non-ICU patients suggest that the 1-µg test may be more sensitive to detect AI; 3 heterogeneous studies in ICU patients confirmed the improved sensitivity of the 1-µg test.

CONCLUSIONS: Use of cosyntropin 1 µg should detect AI in all patients who would have been diagnosed using 250 µg. Unfortunately, all of the clinical trials evaluating the role of corticosteroids in septic shock that used the cosyntropin stimulation test administered 250 µg. Extrapolation of the existing guidelines to treat patients with septic shock testing positive for relative AI using the 1-µg test may provide effective therapy to appropriate patients not diagnosed by the 250-µg testing or may introduce additional adverse effects in patients who should not receive corticosteroids. Large-scale, head-to-head comparison data of steroid effectiveness after 1- and 250-µg ACTH stimulation tests are needed to expand upon these promising results.

Key Words: adrenal insufficiency, corticosteroids, cortisol, cosyntropin

Published Online, March 1, 2005. www.theannals.com, DOI 10.1345/aph.1E139

This article has been cited by other articles:

				Z. Thomas and G. L Fraser An Update on the Diagnosis of Adrenal Insufficiency and the Use of Corticotherapy in Critical Illness Ann. Pharmacother., September 1, 2007; 41(9): 1456 - 1465. [Abstract] [Full Text] [PDF]

				B. M. Arafah Hypothalamic Pituitary Adrenal Function during Critical Illness: Limitations of Current Assessment Methods J. Clin. Endocrinol. Metab., October 1, 2006; 91(10): 3725 - 3745. [Abstract] [Full Text] [PDF]

				P. M. Szumita, B. C. Greenwood, C. M. Lowry, and M. E. Wechsler Using the high-dose corticotropin test to diagnose relative adrenal insufficiency in vasopressor-dependent septic shock Am. J. Health Syst. Pharm., March 1, 2006; 63(5): 466 - 471. [Full Text] [PDF]