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The Journal of Clinical Endocrinology & Metabolism Vol. 82, No. 10 3520
Copyright © 1997 by The Endocrine Society

Letters to the Editor

What Should Be Considered A Low Dose in the ACTH Stimulation Test?1

Gabriel Dickstein

Bnai Zion Medical Center Haifa, 31048, Israel

In their paper, Shankar et al. (1) claim that they found no improvement in the sensitivity of the low dose ACTH test for the evaluation of the HPA axis. However, they use the term "low dose ACTH test" wrongly.

The dose of ACTH in the low dose test was defined previously as being 1.0 µg for adults (2, 3, 4), or 0.5 µg/1.73 m2 for children (5, 6). These were the doses proven to increase sensitivity. Tordjman et al. (3) have shown that 5.0 µg (which equals 0.06–1.0 µg/kg) is too high a dose for this purpose. The dose the authors use in the current study is much higher, equaling about 15 µg for adults and about 10.0 µg/1.73 m2 for children. All that this paper shows is that such a dose does not increase the sensitivity of the ACTH test, which is not surprising, knowing that even lower doses do not.

However, the term "low dose ACTH test" should not have been used in this study, as readers might wrongly think that their low dose ACTH test is similar to the one used in the past and proven to increase sensitivity.

We have also a comment regarding the study design. We find that both ACTH tests (high dose and so called low dose) should not have been done on the same day, and definitely not in the order they were. The correct way should be either to perform tests in random order, as we did (2), or start with the lower dose, as the higher one might prime the adrenal gland, rather than deplete it. Actually, the fact that one patient did not respond to the huge dose of 250 µg but responded to the lower ACTH later in the same day suggests that this is really the case. However, considering the too large ACTH dose used as a low dose, this point is minor in the current study.

Footnotes

1 Received June 19, 1997. Address correspondence to: Gabriel Dickstein, Division of Endocrinology, Oregon Health Sciences University L607, 3181 SW Sam Jackson Park Road, Portland, Oregon 97201-3098. Back

References

  1. Shankar RR, Jakacki RI, Haider A, et al. 1997 Testing the hypothalamic-pituitary-adrenal axis in survivors of childhood brain and skull-based tumors. J Clin Endocrinol Metab. 82:1995–1998.[Abstract/Free Full Text]
  2. Dickstein G, Shechner C, Nicholson WF, et al. 1991 Adrenocorticotropin stimulation test: effects of basal cortisol level, time of day, and suggested new sensitive low dose test. J Clin Endocrinol Metab. 72:772–778.
  3. Tordjman K, Jaffe A, Grazas N, Apter C, Stern N. 1995 The role of the low dose (1 µg) adrenocorticotropin test in the evaluation of patients with pituitary diseases. J Clin Endocrinol Metab. 80:1301–1305.[Abstract]
  4. Rasmuson S, Olsson T, Hagg E. 1996 A low dose ACTH test to assess the function of the hypothalamic-pituitary-adrenal axis. Clin Endocrinol. 44:151–156.[CrossRef][Medline]
  5. Crowley S, Hindmarsh PC, Holownia P, Honour JW, Brook CGD. 1991 The use of low doses of ACTH in the investigation of adrenal function in man. J Endocrinol. 130:475–479.[Abstract/Free Full Text]
  6. Brodie J, Soferman R, Kivity S, et al. 1995 Low dose adrenocorticotropin test reveals impaired adrenal function in patients taking inhaled corticosteroids. J Clin Endocrinol Metab. 80:1243–1246.[Abstract]




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