Many thanks to those who responded to my enquiry;
"Baseline cortisol 127 nmol/l (at 9 am) 30 minutes post synacthen 807.
(not a shift worker) but has 4 kids!! Cortisol was done by one of the
rheumatologists after she complained of tiredness. 9 am cortisol was
slightly low (150 ish)- therefore SST was performed. Not on
medication/herbal tonics? Normal menstrual cycle, sleep pattern? Poor
sleep due to 4 kids?
Any other ideas please?"
your suggestions (and our replies);
What time does get out of bed in the morning and what time does she go to
bed at night. Check her salivary cortisol and/or CBG.(Won't the CBG level
be the same in the unstimulated and stimulated sample?)
? patient using any hydrocortisone containing medication ? other pituitary
hormones please
(Not on any kind of steroid preparation (as far as can be confirmed!).
DrS.R. did ask her specifically about it. No other pituitary hormones
measured. He did not see any need for it. Has regular periods (not on
pill).
Could still be consistent with recent onset secondary hypoadrenalism. Make
sure that she is not on any form of steroid including inhaled therapy.
Hi. All you've done with SST is establish that she doesn't have primary
adrenal insufficiency. If there is a persistent clinical suspicion of
hypoadrenalism, you may need to stress her pituitary, i.e. do insulin
stress test. A word of advice if you do: it's worth doing ACTH at each
time point as well as cortisol - can more convincingly establish adequacy
or otherwise of ACTH reserve. I've a patient with ACTH deficiency in whom
we had to do this to convince ourselves she had it. (We don't think this
is justified given her good general health and would prefer another SST in
6 - 12 months)
These cases are difficult. We see them every now and again and the test is
repeatable. Seems unfair to call them lazy adrenals but maybe that is the
answer; but what to do as the patients feel washed out!
Our endocrinology team appreciates access to so much experienced and
expert advice,
Regards,
David.
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