title: ACTH Stimulation Tests for the Diagnosis of Adrenal Insufficiency: Systematic Review and Meta-Analysis.
abstract: BACKGROUND
  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.
  
  
  RESULTS
  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%).
  
  
  CONCLUSIONS
  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.
authors.affiliation: 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.
authors.forename: Naykky Singh
authors.initials: NS
authors.lastname: Ospina
authors.affiliation: 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.
authors.forename: Alaa
authors.initials: A
authors.lastname: Al Nofal
authors.affiliation: 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.
authors.forename: Irina
authors.initials: I
authors.lastname: Bancos
authors.affiliation: 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.
authors.forename: Asma
authors.initials: A
authors.lastname: Javed
authors.affiliation: 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.
authors.forename: Khalid
authors.initials: K
authors.lastname: Benkhadra
authors.affiliation: 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.
authors.forename: Ekta
authors.initials: E
authors.lastname: Kapoor
authors.affiliation: 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.
authors.forename: Aida N
authors.initials: AN
authors.lastname: Lteif
authors.affiliation: 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.
authors.forename: Neena
authors.initials: N
authors.lastname: Natt
authors.affiliation: 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.
authors.forename: M Hassan
authors.initials: MH
authors.lastname: Murad
mesh_terms: D000309:Adrenal Insufficiency / Q000175:diagnosis*; D000324:Adrenocorticotropic Hormone / Q000494:pharmacology*; D000328:Adult; D002648:Child; D006728:Hormones / Q000494:pharmacology*; D006801:Humans; D011237:Predictive Value of Tests; D015203:Reproducibility of Results
chemical_list: D006728:Hormones; D000324:Adrenocorticotropic Hormone