Medline ® Abstract for Reference 12
of 'Diagnostic testing for hypopituitarism'
ACTH Stimulation Tests for the Diagnosis of Adrenal Insufficiency: Systematic Review and Meta-Analysis.
Ospina NS, Al Nofal A, Bancos I, Javed A, Benkhadra K, Kapoor E, Lteif AN, Natt N, Murad MH
J Clin Endocrinol Metab. 2016 Feb;101(2):427-34. Epub 2015 Dec 9.
CONTEXT: The diagnosis of adrenal insufficiency is clinically challenging and often requires ACTH stimulation tests.
OBJECTIVE: To determine the diagnostic accuracy of the high- (250 mcg) and low- (1 mcg) dose ACTH stimulation tests in the diagnosis of adrenal insufficiency.
METHODS: We searched six databases through February 2014. Pairs of independent reviewers selected studies and appraised the risk of bias. Diagnostic association measures were pooled across studies using a bivariate model.
DATA SYNTHESIS: For secondary adrenal insufficiency, we included 30 studies enrolling 1209 adults and 228 children. High- and low-dose ACTH stimulation tests had similar diagnostic accuracy in adults and children using different peak serum cortisol cutoffs. In general, both tests had low sensitivity and high specificity resulting in reasonable likelihood ratios for a positive test (adults: high dose, 9.1; low dose, 5.9; children: high dose, 43.5; low dose, 7.7), but a fairly suboptimal likelihood ratio for a negative test (adults: high dose, 0.39; low dose, 0.19; children: high dose, 0.65; low dose, 0.34). For primary adrenal insufficiency, we included five studies enrolling 100 patients. Data were only available to estimate the sensitivity of high dose ACTH stimulation test (92%; 95% confidence interval, 81-97%).
CONCLUSION: Both high- and low-dose ACTH stimulation tests had similar diagnostic accuracy. Both tests are adequate to rule in, but not rule out, secondary adrenal insufficiency. Our confidence in these estimates is low to moderate because of the likely risk of bias, heterogeneity, and imprecision.
Evidence-Based Practice Research Program (N.S.O., A.A.N., K.B., M.H.M.), Mayo Clinic, Rochester, Minnesota; Knowledge and Evaluation Research Unit (N.S.O., K.B., M.H.M.), Mayo Clinic, Rochester, Minnesota; Division of Endocrinology, Diabetes, Metabolism, and Nutrition (N.S.O., N.N., I.B.), Mayo Clinic, Rochester, Minnesota; Division of Pediatric Endocrinology and Metabolism (A.A.N., A.J., A.N.L.), Mayo Clinic, Rochester, Minnesota; Division of General Internal Medicine (E.K.), Mayo Clinic, Rochester, Minnesota 55905.