title: Is the plasma ACTH concentration a reliable parameter in the insulin tolerance test?
abstract: OBJECTIVE
  The insulin tolerance test (ITT) is an established standardized test for the evaluation of the hypothalamic-pituitary-adrenal axis. While a peak cortisol value of >18 microg/dl is usually interpreted as a sufficient response to the ITT, the plasma ACTH response has not yet been standardized.
  
  
  METHODS
  We evaluated retrospectively the peak plasma ACTH concentrations during 140 ITTs in 125 patients with suspected pituitary insufficiency and prospectively in 15 healthy subjects.
  
  
  RESULTS
  All healthy subjects had a peak cortisol concentration >/=18 microg/dl; 32 of 125 tests in the patients showed an insufficient cortisol response (peak cortisol concentration <18 microg/dl). The peak stimulated ACTH concentration in patients with secondary adrenal insufficiency (SAI) was 49.2+/-37.2 pg/ml (mean+/-s.d.) vs 130.9+/-89.3 pg/ml in patients without SAI, and 110.9+/-55.4 pg/ml in normal subjects (P<0.001). There was a weak, but significantly positive correlation between the peak ACTH and peak cortisol concentrations (rho=0.446, P<0.001), but there was also a very wide spread of the values. Defining a cut-off value for the peak plasma ACTH concentration with a sufficient sensitivity and specificity to identify patients with an impaired hypothalamic-pituitary-adrenal (HPA) axis was not possible. A peak plasma ACTH <20 pg/ml as a cut-off value had a sensitivity of 25% and a specificity of 98% for SAI. A cut-off value of a peak plasma ACTH <140 pg/ml had a sensitivity of 97% but a low specificity of 39%.
  
  
  CONCLUSIONS
  Although there is a significant positive correlation between the peak ACTH and the peak cortisol concentrations, we conclude that there is no additional benefit in determining the ACTH concentrations during an ITT. Because of the strong variations of the values, the peak ACTH concentration is a poor parameter for the evaluation of the HPA axis.
authors.affiliation: Division of Endocrinology, Department of Medicine 2, University Hospital of Freiburg, Germany. borm@med1.ukl-freiburg.de
authors.forename: K
authors.initials: K
authors.lastname: Borm
authors.forename: M
authors.initials: M
authors.lastname: Slawik
authors.forename: L
authors.initials: L
authors.lastname: Seiler
authors.forename: F
authors.initials: F
authors.lastname: Flohr
authors.forename: M
authors.initials: M
authors.lastname: Petrick
authors.forename: J
authors.initials: J
authors.lastname: Honegger
authors.forename: M
authors.initials: M
authors.lastname: Reincke
mesh_terms: D000309:Adrenal Insufficiency / Q000097:blood / Q000175:diagnosis*; D000324:Adrenocorticotropic Hormone / Q000097:blood*; D005260:Female; D006801:Humans; D006854:Hydrocortisone / Q000097:blood; D007018:Hypopituitarism / Q000097:blood / Q000175:diagnosis*; D007030:Hypothalamo-Hypophyseal System / Q000502:physiology; D007328:Insulin; D008297:Male; D010912:Pituitary-Adrenal Function Tests / Q000379:methods*; D010913:Pituitary-Adrenal System / Q000502:physiology; D010949:Plasma; D012016:Reference Values; D012189:Retrospective Studies
chemical_list: D007328:Insulin; D000324:Adrenocorticotropic Hormone; D006854:Hydrocortisone