title: Cosyntropin stimulation testing on postoperative day 1 allows for selective glucocorticoid replacement therapy after adrenalectomy for hypercortisolism: Results of a novel, multidisciplinary institutional protocol.
abstract: BACKGROUND
  Secondary adrenal insufficiency (AI) can occur after unilateral adrenalectomy for adrenal-dependent hypercortisolism. Postoperative glucocorticoid replacement (GR), although given routinely, may not be necessary. We sought to identify factors that, in combination with postoperative day 1 cosyntropin stimulation testing (POD1-CST), would predict the need for GR.
  
  
  METHODS
  We reviewed 31 consecutive patients who underwent unilateral adrenalectomy for hypercortisolism (study patients) or hyperaldosteronism (control patients). A standard POD1-CST protocol was used. Hydrocortisone was started for clinical evidence of AI, basal plasma cortisol ≤ 5 (μg/dL), or a stimulated plasma cortisol <18.
  
  
  RESULTS
  A normal POD1-CST was found in all nine control patients and 11 of 22 patients (50%) with Cushing's syndrome; the other 11 study patients (50%) received GR based on the POD1-CST. These patients were younger (51 vs 62 years; P = .017), had a higher body mass index (BMI; 31 vs 29 kg/m(2)), and smaller adrenal neoplasms (16.9 vs 33.0 g; P = .009) than non-GR study patients.
  
  
  CONCLUSIONS
  After unilateral adrenalectomy for hypercortisolism, only 50% of patients received GR. No preoperative biochemical characteristics were associated with postoperative AI, although patients who received GR were younger, and tended to have a higher BMI and smaller adrenal nodules. Use of this novel protocol for postoperative dynamic adrenal function testing prevented unnecessary GR in 50% of patients and allowed for individualized patient care.
authors.affiliation: Department of Surgery, Medical College of Wisconsin, Milwaukee, WI. Electronic address: diortiz@mcw.edu.
authors.forename: Diana I
authors.initials: DI
authors.lastname: Ortiz
authors.affiliation: Endocrine Center and Clinics, Medical College of Wisconsin, Milwaukee, WI.
authors.forename: James W
authors.initials: JW
authors.lastname: Findling
authors.affiliation: Endocrine Center and Clinics, Medical College of Wisconsin, Milwaukee, WI.
authors.forename: Ty B
authors.initials: TB
authors.lastname: Carroll
authors.affiliation: Endocrine Center and Clinics, Medical College of Wisconsin, Milwaukee, WI.
authors.forename: Bradley R
authors.initials: BR
authors.lastname: Javorsky
authors.affiliation: Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.
authors.forename: Azadeh A
authors.initials: AA
authors.lastname: Carr
authors.affiliation: Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.
authors.forename: Douglas B
authors.initials: DB
authors.lastname: Evans
authors.affiliation: Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.
authors.forename: Tina W
authors.initials: TW
authors.lastname: Yen
authors.affiliation: Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.
authors.forename: Tracy S
authors.initials: TS
authors.lastname: Wang
mesh_terms: D000304:Adrenal Cortex Function Tests; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage*; D000306:Adrenal Cortex Neoplasms / Q000150:complications / Q000601:surgery*; D000309:Adrenal Insufficiency / Q000175:diagnosis* / Q000178:diet therapy / Q000209:etiology; D000315:Adrenalectomy / Q000009:adverse effects*; D000328:Adult; D000368:Aged; D002985:Clinical Protocols; D003366:Cosyntropin / Q000008:administration & dosage*; D003480:Cushing Syndrome / Q000209:etiology / Q000601:surgery*; D005260:Female; D020249:Hormone Replacement Therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D055815:Young Adult
chemical_list: D000305:Adrenal Cortex Hormones; D003366:Cosyntropin