Thaler L M, Blevins L S
Department of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia 30322, USA.
J Clin Endocrinol Metab. 1998 Aug;83(8):2726-9. doi: 10.1210/jcem.83.8.5039.
Currently, the most popular test for adrenal insufficiency is the conventional rapid ACTH stimulation test (250 microg ACTH). This method is quick and safe, but incorporates a dose of ACTH that is supraphysiological and capable of transiently stimulating the adrenal cortex in many patients with documented central adrenal insufficiency. In recent years, several investigators have published substantial evidence for a more sensitive ACTH stimulation test using a lower dose of ACTH (1 microg). Further analysis of these data, including the calculation of likelihood ratios, demonstrates that the 1-microg test performs significantly better than the 250-microg test compared to the gold standard, insulin tolerance test. We suggest that the 1-microg ACTH stimulation test replace the conventional 250-microg test when evaluating for central adrenal insufficiency. A cortisol level below 500 nmol/L after 30 min signifies impaired adrenocortical reserve. An insulin tolerance test should be performed if this low dose test results in a borderline value and the diagnosis is questioned. The 1-microg test should not be used if recent pituitary injury is suspected. Pharmaceutical companies should be encouraged to provide synthetic ACTH in 1-microg vials.
目前，用于检测肾上腺功能不全最常用的方法是传统的快速促肾上腺皮质激素（ACTH）刺激试验（250微克ACTH）。该方法快速且安全，但所采用的ACTH剂量超过生理水平，能够在许多已确诊为中枢性肾上腺功能不全的患者中短暂刺激肾上腺皮质。近年来，一些研究人员发表了大量证据，支持采用较低剂量ACTH（1微克）进行更敏感的ACTH刺激试验。对这些数据的进一步分析，包括似然比的计算，表明与金标准胰岛素耐量试验相比,1微克试验的表现明显优于250微克试验。我们建议在评估中枢性肾上腺功能不全时，采用1微克ACTH刺激试验取代传统的250微克试验。30分钟后皮质醇水平低于500纳摩尔/升表明肾上腺皮质储备功能受损。如果该低剂量试验结果处于临界值且对诊断存在疑问，则应进行胰岛素耐量试验。如果怀疑近期有垂体损伤，则不应使用1微克试验。应鼓励制药公司提供1微克瓶装的合成ACTH。
