Dorin Richard I, Qualls Clifford R, Crapo Lawrence M
Division of Endocrinology and Metabolism, New Mexico Veterans Administration Health Care System and University of New Mexico, Medical Service 111, 1501 San Pedro Boulevard SE, Albuquerque, New Mexico 87108, USA.
Ann Intern Med. 2003 Aug 5;139(3):194-204. doi: 10.7326/0003-4819-139-3-200308050-00009.
The cosyntropin stimulation test is the initial endocrine evaluation of suspected primary or secondary adrenal insufficiency.
To critically review the utility of the cosyntropin stimulation test for evaluating adrenal insufficiency.
The MEDLINE database was searched from 1966 to 2002 for all English-language papers related to the diagnosis of adrenal insufficiency.
Studies with fewer than 5 persons with primary or secondary adrenal insufficiency or with fewer than 10 persons as normal controls were excluded. For secondary adrenal insufficiency, only studies that stratified participants by integrated tests of adrenal function were included.
Summary receiver-operating characteristic (ROC) curves were generated from all studies that provided sensitivity and specificity data for 250-microg and 1-microg cosyntropin tests; these curves were then compared by using area under the curve (AUC) methods. All estimated values are given with 95% CIs.
At a specificity of 95%, sensitivities were 97%, 57%, and 61% for summary ROC curves in tests for primary adrenal insufficiency (250-microg cosyntropin test), secondary adrenal insufficiency (250-microg cosyntropin test), and secondary adrenal insufficiency (1-microg cosyntropin test), respectively. The area under the curve for primary adrenal insufficiency was significantly greater than the AUC for secondary adrenal insufficiency for the high-dose cosyntropin test (P < 0.001), but AUCs for the 250-microg and 1-microg cosyntropin tests did not differ significantly (P > 0.5) for secondary adrenal insufficiency. At a specificity of 95%, summary ROC analysis for the 250-microg cosyntropin test yielded a positive likelihood ratio of 11.5 (95% CI, 8.7 to 14.2) and a negative likelihood ratio of 0.45 (CI, 0.30 to 0.60) for the diagnosis of secondary adrenal insufficiency.
Cortisol response to cosyntropin varies considerably among healthy persons. The cosyntropin test performs well in patients with primary adrenal insufficiency, but the lower sensitivity in patients with secondary adrenal insufficiency necessitates use of tests involving stimulation of the hypothalamus if the pretest probability is sufficiently high. The operating characteristics of the 250-microg and 1-microg cosyntropin tests are similar.
促肾上腺皮质激素刺激试验是对疑似原发性或继发性肾上腺功能不全进行的初步内分泌评估。
严格审查促肾上腺皮质激素刺激试验在评估肾上腺功能不全中的效用。
检索1966年至2002年的MEDLINE数据库，查找所有与肾上腺功能不全诊断相关的英文论文。
排除原发性或继发性肾上腺功能不全患者少于5例或正常对照少于10例的研究。对于继发性肾上腺功能不全，仅纳入通过肾上腺功能综合测试对参与者进行分层的研究。
从所有提供250微克和1微克促肾上腺皮质激素试验敏感性和特异性数据的研究中生成汇总受试者工作特征（ROC）曲线；然后使用曲线下面积（AUC）方法比较这些曲线。所有估计值均给出95%置信区间。
在特异性为95%时，原发性肾上腺功能不全（250微克促肾上腺皮质激素试验）、继发性肾上腺功能不全（250微克促肾上腺皮质激素试验）和继发性肾上腺功能不全（1微克促肾上腺皮质激素试验）的汇总ROC曲线的敏感性分别为97%、57%和61%。高剂量促肾上腺皮质激素试验中，原发性肾上腺功能不全的曲线下面积显著大于继发性肾上腺功能不全的AUC（P<0.001），但继发性肾上腺功能不全的250微克和1微克促肾上腺皮质激素试验的AUC差异不显著（P>0.5）。在特异性为95%时，250微克促肾上腺皮质激素试验的汇总ROC分析得出继发性肾上腺功能不全诊断的阳性似然比为11.5（95%CI，8.7至14.2），阴性似然比为0.45（CI，0.30至0.60）。
健康人对促肾上腺皮质激素的皮质醇反应差异很大。促肾上腺皮质激素试验在原发性肾上腺功能不全患者中表现良好，但在继发性肾上腺功能不全患者中敏感性较低，如果试验前概率足够高，则需要使用涉及刺激下丘脑的试验。250微克和1微克促肾上腺皮质激素试验的操作特征相似。
