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Table 5 Screening recommendations for AS

From: Adrenal suppression: A practical guide to the screening and management of this under-recognized complication of inhaled corticosteroid therapy

When to Screen? Patient has persistent symptoms of AS: Weakness/fatigue, malaise, nausea, vomiting, diarrhea, abdominal pain, headache (usually in the morning), poor weight gain, myalgia, arthralgia, psychiatric symptom, poor growth, hypotension*, hypoglycemia*
Patient has been receiving high-dose ICS therapy for 3-6 months: ≥500 μg/day of fluticasone; ≥1000 μg/day of budesonide/beclomethasone; or >1000 μg/day of ciclesonide
Patient has received oral corticosteroids for: >2 consecutive weeks or >3 cumulative weeks in the last 6 months
Patient using concomitant ICS therapy and potent CYP3A4 inhibitors, particularly antiretroviral and antifungal agents
  Complete first morning (08:00 am) cortisol test
     - Must be completed by 8:00 am or earlier
     - No oral glucocorticoids the evening and morning prior to the test
     - Fasting not required
How to Screen? If result is normal, screen again in 6 months
  If result is normal but patient has symptoms of AS, perform low-dose ACTH stimulation test to confirm diagnosis:
     - 1 μg of cosyntropin; cortisol levels taken at 0, 15-20 and 30 minutes
     - Peak cortisol < 500 nmol/L = AS (peak >500 nmol/L is normal)
When to be Concerned? 8:00 am cortisol value < 85 nmol/L = diagnosis of AS
8:00 am cortisol value < laboratory normal = possible AS; consider endocrinology referral for confirmation of diagnosis
  1. AS: adrenal suppression; ICS: inhaled corticosteroid
  2. *Symptoms of adrenal crisis require emergent management