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The morning cortisol reference range is broad, and a patient can have adrenal insufficiency but maintain basal acth and/or cortisol secretion within the range of normal. An abnormal response does not evolve until the volume of the adrenal cortex has decreased significantly. Acth measurement — the plasma corticotropin (acth) level can help distinguish between primary and central (ie, secondary or tertiary) adrenal insufficiency (algorithm 1)

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It can be measured with an early morning serum cortisol (ie, by 8 am) as part of the initial evaluation for adrenal insufficiency. If acth deficiency occurs as a result of transsphenoidal surgery, the cortisol response to exogenous acth stimulation may be normal in the first month or two after surgery For night shift workers, measure basal serum cortisol when the individual wakes up

If primary adrenal insufficiency is suspected (eg, orthostatic hypotension with additional signs and symptoms), measure cortisol, acth, renin, and aldosterone levels simultaneously to expedite the diagnosis.

Glucocorticoids — cortisol is the main glucocorticoid produced by the adrenal glands Corticotropin, or acth, is made in the pituitary and stimulates the adrenal glands to produce cortisol. Dexamethasone suppression tests (dsts) are primarily used to screen for excess cortisol production (cushing syndrome) and are useful in detecting dysregulated cortisol hypersecretion in adrenal incidentalomas. Morning serum cortisol — to test basal acth secretion, we suggest measuring a morning serum cortisol (at 6 to 9 am) (algorithm 1)

The interpretation of the cortisol result depends on the type of assay that is used to measure it.