To the Editor.—Despite the recent findings of Cunningham et al,1 the synthetic adrenocorticotropic hormone (ACTH) test remains the best technique for establishing whether a patient with possible adrenal insufficiency secondary to exogenous glucocorticoid therapy can undergo the stress of surgery without supplemental steroid coverage.
Jasani et al2 found in 1968 that the metyrapone and insulin-induced hypoglycemia tests were more sensitive than the ACTH stimulation test in detecting mild degrees of secondary adrenal insufficiency. They studied 21 patients with steroid-treated rheumatoid arthritis undergoing anterior synovectomy of the knee without steroid coverage. Preoperatively, 16 patients had abnormal responses to the metyrapone or insulin-induced hypoglycemia tests, and nine of these 16 patients also had abnormal ACTH stimulation test results. Only one patient, from the group with abnormal responses to the ACTH test, developed intraoperative hypotension associated with a low serum cortisol.
These results are further supported by the work of