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Summary The talk will focus on two areas, the diagnosis of Cushings syndrome and adrenal insufficiency.
Endogenous Cushing syndrome (CS) refers to pathologic hypercortisolism and is associated with significant morbidity, mortality, and reduction in quality of life. The diagnosis of CS can often be challenging as CS is typically characterized by the presence of multiple symptoms (such as hypertension, diabetes, weight gain, or osteoporosis) which are very common in the general population.To date, there is no consensus as to the gold standard screening test for the diagnosis of CS, and the presence of at least two abnormal tests with high diagnostic accuracy is needed. The latest consensus recommended that if CS is suspected any combination of Overnight Dexamethasone Suppression Test (ODST), Urinary Free Cortisol (UFC), and Late-Night Salivary Cortisol (LNSC) tests can be helpful. For patients with adrenal incidentalomas being evaluated for hypercortisolism, ODST is recommended as a first test, with consideration of additional UFC and/ or LNSC measurements. We will discuss the role of salivary cortisone in both late night collections and after a dexamethasone suppression test.
Adrenal insufficiency, or cortisol deficiency, is a life-threatening condition which can be primary (adrenal), secondary (pituitary) and tertiary (mainly adrenal suppression secondary to glucocorticoids or opioids). Prevalence is rising due to the increased prescription of glucocorticoid and opioid therapies that suppress adrenal function. The standard tests for adrenal insufficiency are a morning serum cortisol and/or the Adrenocorticotropin (ACTH) Stimulation Test (AST), also called the Short Synacthen Test, and it is estimated that 90, 000 ASTs are performed a year in the UK. The AST and serum cortisol require patients to attend a clinical centre and undergo venesection and the administration of Synacthen (Co-syntropin); the AST is classed as an inpatient admission with an associated inpatient tariff. The waiting times associated with scheduling the AST can result in delayed diagnosis . It has recently been shown in a diagnostic accuracy study that home waking salivary cortisone is an accurate screening test for adrenal insufficiency. The test is simple to perform and, as salivary cortisone is stable at room temperature, it may be carried out at home and then sent by post to the laboratory, making it easier for the patient, and reducing health care costs. The diagnostic accuracy study showed that home waking salivary cortisone predicted the cortisol response to synacthen in the AST and if home waking salivary cortisone were used to screen patients, then it would have obviated the need for an AST in 70% of patients.
Bridging the gap between research and the clinic is important but not simple and it may take years to convince stakeholders and clinicians to change their clinical practise. A new test should be introduced with robust evidence, and barriers to implementation need to be sought and addressed. We will discuss the introduction of this test into routine clinical care.
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