Relationship between cortisol increment and basal cortisol: implications for the low-dose short adrenocorticotropic hormone stimulation test.

BACKGROUND We analyzed the low-dose (1 microg) rapid adrenocorticotropic hormone test (LDST) in 17 patients with a normal hypothalamic-pituitary-adrenal axis to determine reference intervals for the LDST on the basis of poststimulation cortisol increments. METHODS We analyzed test results for 17 patients (14 females and 3 males; age range, 18-46 years) who had received a 2-mL aliquot of low-dose (1 microg) adrenocorticotropic hormone prepared from one 250-microg vial of Synacthen diluted in 500 mL of sterile normal saline solution. Sampling took place at 0, 20, 30, and 60 min post stimulation. The cortisol increment was plotted against basal cortisol. RESULTS We observed a marked interdependence of the basal cortisol concentration with the increase in cortisol concentration. The relationship was inverse and linear with the best fit observed at 30 min post stimulation. The lower 95% prediction limit for basal cortisol at the zero increment was 400 nmol/L with a mean concentration of 600 nmol/L. CONCLUSIONS We propose that a peak cortisol concentration <400 nmol/L is a sufficient single criterion for abnormal adrenal function as assessed by the LDST. Concentrations of 400-600 nmol/L are in the gray area, and those >600 nmol/L confirm normal adrenal function. Repeat analyses with larger sample sizes are warranted to confirm these observations.