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On the other hand, the management of relative AI remains controversial. Overt primary AI also necessitates mineralocorticoid replacement. Patients with overt primary and secondary AI require glucocorticoid replacement therapy. A high index of clinical suspicion is needed in the detection of AI, especially in PLHIV, as it may present insidiously with non-specific signs and symptoms and may be potentially life threatening if left untreated. Physicians need to be aware of the endocrinological implications of HIV infection and its treatment, especially CYP3A4 enzyme inhibitors. A literature review was conducted through Medline and Google Scholar search on the subject. It also focuses on the pathophysiology, aetiology, diagnosis and management of this endocrinopathy in PLHIV. In this review, the authors explore the definitions of relative AI, primary AI, secondary AI and peripheral glucocorticoid resistance in PLHIV.
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In this review, we summarise the current status of HPA axis suppression and the SAI associated with GC therapy in brain tumours.Īdrenal insufficiency (AI) is one of the most common potentially life-threatening endocrine complications in people living with human immunodeficiency virus (PLHIV) infection and acquired immunodeficiency syndrome (AIDS). In the context of brain tumours, limited evidence exists to guide clinical practice regarding the optimal dosing of GC with regard to side effects, duration of therapy, withdrawal regimen or quality of life. Hydrocortisone replacement is the recommended therapy for SAI as it provides the physiological circadian cortisol rhythm. Furthermore, a variety of well‐established dynamic tests have been used to diagnose and assess the integrity of the HPA axis, such as the insulin tolerance test, the metyrapone stimulation test and the adrenocorticotropic hormone stimulation test. Moreover, abrupt tapering and sudden stopping of GC therapy are the most common causes of HPA axis suppression leading to secondary adrenal insufficiency (SAI). In contrast, prolonged exposure to GC has been associated with suppression of the hypothalamic–pituitary–adrenal (HPA) axis. Glucocorticoids (GC) are the mainstay supportive therapy for a variety of disorders associated with brain tumours such as vasogenic oedema, intracranial pressure, headache, and vomiting. The majority of brain tumours are associated with perifocal oedemas and disturbances in the cerebrospinal fluid (CSF) flow. The operating characteristics of the 250-microg and 1-microg cosyntropin tests are similar.īrain tumours are among the most challenging malignancies to treat. 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. 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.Ĭortisol response to cosyntropin varies considerably among healthy persons. 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 0.5) for secondary adrenal insufficiency. All estimated values are given with 95% CIs.Īt 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. 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. For secondary adrenal insufficiency, only studies that stratified participants by integrated tests of adrenal function were included. Studies with fewer than 5 persons with primary or secondary adrenal insufficiency or with fewer than 10 persons as normal controls were excluded. The MEDLINE database was searched from 1966 to 2002 for all English-language papers related to the diagnosis of adrenal insufficiency.
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To critically review the utility of the cosyntropin stimulation test for evaluating adrenal insufficiency. The cosyntropin stimulation test is the initial endocrine evaluation of suspected primary or secondary adrenal insufficiency.
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