DHEAS may serve as biomarker for diagnosing adrenal insufficiency
Key takeaways:
- DHEAS levels had a similar accuracy for diagnosing adrenal insufficiency as baseline cortisol.
- More biomarkers may be needed for diagnosing adrenal insufficiency with recent glucocorticoid use.
The use of dehydroepiandrosterone sulfate to determine an adrenal insufficiency diagnosis has similar accuracy to using baseline cortisol level, according to findings published in The Journal of Clinical Endocrinology & Metabolism.
“Currently, adrenal insufficiency is underdiagnosed and undertreated due to its vague symptomatology, which can lead to impaired quality of life and worse health outcomes, including life-threatening complications such as adrenal crisis,” Irina Bancos, MD, MSc, professor of medicine and adrenal lab principal investigator in the division of endocrinology, metabolism and nutrition at Mayo Clinic, told Healio. “Baseline cortisol level alone is indeterminate due to short half-life and diurnal variation for many patients; and current dynamic tests are time-consuming, expensive and not available at all centers. Identifying a biomarker such as dehydroepiandrosterone sulfate (DHEAS) that is a simple lab draw, does not have diurnal variation, and accurately assesses for adrenal insufficiency can help streamline the diagnostic process.”
Bancos and colleagues conducted a retrospective study of 1,135 adults who had cosyntropin stimulation testing performed from 2005 to 2023 plus a DHEAS measure collected from 3 months before or 1 week after cosyntropin stimulation testing (median age, 42.8 years; 78.6% women). Adrenal insufficiency was defined as a cortisol level of less than 18 µg/dL 1 hour after cosyntropin stimulation testing.
In the cohort, 17.2% of patients were diagnosed with adrenal insufficiency. Both baseline cortisol and DHEAS had an area under the receiver operating characteristic curve (AUROC) of 0.81 for diagnosing adrenal insufficiency.
Baseline cortisol had an AUROC of 0.83 for adults who underwent testing before 10 a.m. vs. an AUROC of 0.8 for testing performed at or after 10 a.m. DHEAS had a higher AUROC among participants who did not use glucocorticoids in the prior 2 months compared with those who had recently used glucocorticoids (0.83 vs. 0.72).
When different cutoffs were assessed, a baseline cortisol level of less than 10 µg/dL yielded a sensitivity of 96% and specificity of 30% for diagnosing adrenal insufficiency. Specificity increased to 40% when adults who had testing performed after 10 a.m. were excluded. A DHEAS concentration of less than 100 µg/dL had a 90% sensitivity and 43% specificity for diagnosing adrenal insufficiency. Sensitivity increased to 92% and specificity to 46% when adults who used glucocorticoids within the past 2 months were excluded.
Adrenal insufficiency was diagnosed in 1.2% of adults with a baseline cortisol level of 10 µg/dL or higher. Of those with a baseline cortisol of less than 5 µg/dL and DHEAS of less than 25 µg/dL, 72.2% were diagnosed with adrenal insufficiency after cosyntropin stimulation testing. The proportion of adults with a baseline cortisol of 5 µg/dL to 9.9 µg/dL and a DHEAS level of 60 µg/dL diagnosed with adrenal insufficiency was 1.3%.
Bancos said the findings support the use of DHEAS to help identify adrenal insufficiency, as it can lead to a more accurate and quicker diagnosis of the condition.
“DHEAS should be routinely measured along with baseline cortisol as this can prevent the need for further dynamic testing in many patients,” Bancos said.
Two populations where DHEAS levels should be interpreted with caution in diagnosing adrenal insufficiency are adults who recently used glucocorticoids and postmenopausal women, and more research is needed to find additional biomarkers for those populations, according to Bancos.
For more information:
Irina Bancos, MD, MSc, can be reached at bancos.irina@mayo.edu.
Perspective
Back to Top
Adrenal insufficiency is a life-threatening condition that can be divided into primary or secondary. Primary adrenal insufficiency presents as a problem in the steroid’s biosynthesis or in the adrenal gland. In secondary adrenal insufficiency, the problem is mainly in the lack of adrenocorticotropic hormone (ACTH) production from the pituitary. DHEAS is produced mainly in the zona reticularis of the adrenal gland, is ACTH-dependent, has a longer half-life and lacks diurnal variation. Oftentimes, adrenal insufficiency is challenging to diagnose, especially if the cortisol levels are indeterminate. Is there another marker besides the cortisol level that could facilitate the diagnosis of adrenal insufficiency and decrease the need for further dynamic testing, such as cosyntropin stimulation testing?
To answer this question, Han and colleagues analyzed the relationship between baseline cortisol and DHEAS levels to evaluate for adrenal insufficiency. They performed a single-center retrospective cohort study analyzing 1,135 patients. The study found that both baseline cortisol and DHEAS independently can correlate in assessing adrenal insufficiency. In addition, they found that DHEAS is helpful in the decision-making process, especially when cortisol level is less than 9.9 µg/dL, and could help clinicians decide which patients need cosyntropin stimulation testing.
This study reflects the need to implement an algorithm where both markers are ordered at the same time. This could change the clinical practice and expedite the diagnosis so that treatment can be started sooner, and the chances of life-threatening complications can be decreased.
Collapse
Read more about