Performance of glucagon stimulation test in diagnosing central adrenal insufficiency in children when utilising the Roche Elecsys® cortisol II assay: a pilot study

Ekkehard Werner Zöllner; Carl J. Lombard; Annalise E. Zemlin

doi:10.1515/jpem-2022-0252

Article

Performance of glucagon stimulation test in diagnosing central adrenal insufficiency in children when utilising the Roche Elecsys^® cortisol II assay: a pilot study

Ekkehard Werner Zöllner , Carl J. Lombard and Annalise E. Zemlin

Published/Copyright: September 6, 2022

Published by

Become an author with De Gruyter Brill

Submit Manuscript Author Information Explore this Subject

From the journal Journal of Pediatric Endocrinology and Metabolism Volume 35 Issue 10

Abstract

Objectives

The glucagon stimulation test (GST) is used for the simultaneous assessment of central adrenal insufficiency (CAI) and growth hormone deficiency. The new Roche cortisol II (C II) assay was recently introduced, confounding interpretation of the GST. The performance of the GST in diagnosing central adrenal insufficiency (CAI), utilising the C II assay, was therefore compared with that of the overnight metyrapone test (ONMTPT).

Methods

A diagnostic accuracy study was performed by retrospectively analysing folders and laboratory records of 25 children and adolescents investigated for hypopituitarism with the GST and the ONMTPT between September 2016 and December 2019. The peak serum cortisol (C) of the GST, the post-metyrapone serum 11-deoxycortisol and adrenocorticotropin levels of the ONMTPT were recorded. Diagnostic performance of the GST at a previously suggested cut-off of 374 nmol/L was evaluated.

Results

Seventeen boys and 8 girls, aged 1.7–16.3 years (median 7.3 years) were identified. The sensitivity of the post-GST C-level at 374 nmol/L was 0.40 (95% confidence interval [CI] 0.17–0.69), specificity 0.64 (95% CI 0.39–0.84), positive predictive value 0.44 (95% CI 0.19–0.73), negative predictive value 0.60 (95% CI 0.36–0.80), accuracy 0.54 (95% CI 0.35–0.72), positive likelihood ratio (+LR) 0.93 (95% CI 0.49–1.77) and negative LR 1.12 (95% CI 0.40–3.15). The area under the receiver of operating characteristics (ROC) curve was 0.379 (95% CI 0.142–0.615).

Conclusions

This study suggests that the GST at any C II cut-off cannot replace the ONMTPT as a diagnostic test for CAI in children. Findings should be confirmed in a larger study.

Keywords: adrenal; adrenal insufficiency; cortisol; glucagon; metyrapone; pituitary-adrenal function tests

Corresponding author: Ekkehard Werner Zöllner, Associate Professor, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, PO Box 241, 8000, Cape Town, South Africa, E-mail: zollner@sun.ac.za

Acknowledgments

The authors express their gratitude to all the registrars and medical officers who performed the tests as well as the laboratory staff who analysed the samples.

Research funding: None declared.
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
Competing interests: Authors state no conflict of interest.
Informed consent: Informed consent for the overnight metyrapone test is routinely obtained from all parents/children admitted for this test.
Ethical approval: The research related to human use complied with all the relevant national regulations and institutional policies in accordance with the tenets of the Helsinki declaration. The study was approved by the Health Research Ethics Committee (HREC) of the Stellenbosch University (HREC number N21/03/031).

References

1. Böttner, A, Kratzsch, J, Liebermann, S, Keller, A, Pfäffle, RW, Kiess, W, et al.. Comparison of adrenal function tests in children – the glucagon stimulation test allows the simultaneous assessment of adrenal function and growth hormone response in children. J Pediatr Endocrinol Metab 2005;18:433–42. https://doi.org/10.1515/jpem.2005.18.5.433.Search in Google Scholar PubMed

2. Cegla, J, Jones, B, Seyani, L, Papadoulou, D, Wynne, K, Martin, NM, et al.. Comparison of the overnight metyrapone and glucagon stimulation tests in the assessment of secondary hypoadrenalism. Clin Endocrinol 2013;78:738–42. https://doi.org/10.1111/cen.12043.Search in Google Scholar PubMed

3. Zöllner, EW. Hypothalamic-pituitary-adrenal axis suppression in asthmatic children on inhaled corticosteroids: part 1. Which test should be used? Pediatr Allergy Immunol 2007;18:401–9. https://doi.org/10.1111/j.1399-3038.2007.00540.x.Search in Google Scholar PubMed

4. Leong, KS, Walker, AB, Martin, I, Wile, D, Wilding, J, MacFarlane, IA. An audit of 500 subcutaneous glucagon stimulation tests to assess growth hormone and ACTH secretion in patients with hypothalamic-pituitary disease. Clin Endocrinol 2001;54:463–8. https://doi.org/10.1046/j.1365-2265.2001.01169.x.Search in Google Scholar PubMed

5. Lim, SH, Vasanwala, R, Lek, N, Yap, F. Quantifying the risk of hypoglycaemia in children undergoing the glucagon stimulation test. Clin Endocrinol 2011;75:489–94. https://doi.org/10.1111/j.1365-2265.2011.04117.x.Search in Google Scholar PubMed

6. Karaca, Z, Grossman, A, Kelestimur, F. Investigation of the Hypothalamo-pituitary-adrenal (HPA) axis: a contemporary synthesis. Rev Endocr Metab Disord 2021;22:179–204. https://doi.org/10.1007/s11154-020-09611-3.Search in Google Scholar PubMed

7. Di Iorgi, N, Napoli, F, Allegri, A, Secco, A, Calandra, E, Calcagno, A, et al.. The accuracy of the glucagon stimulation test in the diagnosis of adrenal insufficiency in young children with growth hormone deficiency. J Clin Endocrinol Metab 2010;95:2132–9. https://doi.org/10.1210/jc.2009-2697.Search in Google Scholar PubMed

8. Raverot, V, Richet, C, Morel, Y, Raverot, G, Borson-Chazot, F. Establishment of revised diagnostic cut-offs for adrenal laboratory investigation using the new roche diagnostics elecsys cortisol II assay. Ann Endocrinol 2016;77:620–2. https://doi.org/10.1016/j.ando.2016.05.002.Search in Google Scholar PubMed

9. Kline, GA, Buse, J, Krause, RD. Clinical implications for biochemical diagnostic thresholds of adrenal sufficiency using a highly specific cortisol immunoassay. Clin Biochem 2017;50:475–80. https://doi.org/10.1016/j.clinbiochem.2017.02.008.Search in Google Scholar PubMed

10. Hawley, JM, Owen, LJ, Lockhart, SL, Monaghan, PJ, Armston, A, Chadwick, CA, et al.. Serum cortisol: an up-to-date assessment of routine assay performance. Clin Chem 2016;62:1220–9. https://doi.org/10.1373/clinchem.2016.255034.Search in Google Scholar PubMed

11. Vogeser, M, Kratzsch, J, Bae, YJ, Bruegel, M, Ceglarek, U, Fiers, T, et al.. Multicenter performance evaluation of a second generation cortisol assay. Clin Chem Lab Med 2017;55:826–35. https://doi.org/10.1515/cclm-2016-0400.Search in Google Scholar PubMed

12. Grassi, G, Morelli, V, Cerlotti, F, Polledri, E, Fustinoni, S, D’Agostino, S, et al.. Minding the gap between cortisol levels measured with second-generation assays and current diagnostic thresholds for the diagnosis of adrenal insufficiency: a single-center experience. Hormones 2020;19:425–31. https://doi.org/10.1007/s42000-020-00185-y.Search in Google Scholar PubMed PubMed Central

13. Flück, CE. Assessing the function of the human adrenal cortex. In: Ranke, MB, Mullis, PE, editors. Diagnostics of endocrine function in children and adolescents. Basel: Karger; 2011:350–78 pp.10.1159/000327417Search in Google Scholar

14. Zöllner, EW, Lombard, C, Galal, U, Hough, S, Irusen, E, Weinberg, E. Hypothalamicpiuitary-adrenal axis suppression in asthmatic school children. Pediatrics 2012;130:e1512–9. https://doi.org/10.1542/peds.2012-1147.Search in Google Scholar PubMed

15. Ach, T, Yosra, H, Jihen, M, Asma, BA, Maha, K, Molka, C, et al.. Cortisol cut-points for the glucagon stimulation test in the evaluation of hypothalamic pituitary adrenal axis. Endocr J 2018;65:935–42. https://doi.org/10.1507/endocrj.ej18-0147.Search in Google Scholar PubMed

16. Berg, C, Meinel, T, Lahner, H, Yuece, A, Mann, K, Petersenn, S. Diagnostic utility of the glucagon stimulation test in comparison to the insulin tolerance test in patients following pituitary surgery. Eur J Endocrinol 2010;162:477–82. https://doi.org/10.1530/eje-09-0824.Search in Google Scholar

17. Hamrahian, AH, Yuen, KCJ, Gordon, MB, Pulaski-Liebert, KJ, Benna, J, Biller, BMK. Revised GH and cortisol cut-points for the glucagon stimulation test in the evaluation of HG and hypothalamic-pituitary-adrenal axes in adults: results from a prospective randomized multicenter study. Pituitary 2016;19:332–41. https://doi.org/10.1007/s11102-016-0712-7.Search in Google Scholar PubMed

18. El-Farhan, N, Rees, DA, Evans, C. Measuring cortisol in serum, urine and saliva – are our assays good enough? Ann Clin Biochem 2017;54:308–22. https://doi.org/10.1177/0004563216687335.Search in Google Scholar PubMed

19. Littley, MD, Gibson, S, White, A, Shalet, SM. Comparison of the ACTH and cortisol responses to provocative testing with glucagon and insulin hypoglycaemia in normal subjects. Clin Endocrinol 1989;31:527–33. https://doi.org/10.1111/j.1365-2265.1989.tb01276.x.Search in Google Scholar PubMed

20. Staub, JJ, Noelpp, B, Girard, J, Baumann, JB, Graf, RJG. The short metyrapone test: comparison of the plasma ACTH response to metyrapone and insulin-induced hypoglycaemia. Clin Endocrinol 1979;10:595–601. https://doi.org/10.1111/j.1365-2265.1979.tb02119.x.Search in Google Scholar PubMed

Supplementary Material

The online version of this article offers the supplementary material (https://doi.org/10.1515/jpem-2022-0252).

Received: 2022-05-10

Accepted: 2022-08-16

Published Online: 2022-09-06

Published in Print: 2022-10-26

You are currently not able to access this content.

Supplementary Material

Articles in the same Issue

https://doi.org/10.1515/jpem-2022-0252

Keywords for this article

adrenal; adrenal insufficiency; cortisol; glucagon; metyrapone; pituitary-adrenal function tests