Preoperative Assessment of Adrenal Insufficiency in Glucocorticoid Therapy-Reply

In Reply.—Dr Thygeson asserts that the ACTH test provides the best method of identifying patients at risk of adrenal insufficiency following treatment with glucocorticoids. Thygeson is apparently addressing the specificity of the ACTH test for the possible emergence of intraoperative hypotension rather than sensitivity to the wide spectrum of clinical and biochemical manifestations of adrenal insufficiency. Since the population und[ill] review are patients previously trea[ill] with glucocorticoids and would th[ill] fore be expected to have intact fu[ill] tioning of the renin-angiotensin-[ill] sterone system, the emergence of [ill] potension would be a late event. article by Jasani cited by Thyge[ill] demonstrates that patients with [ill] paired preoperative responses to [ill] poglycemia and/or metyrapone [ill] subnormal cortisol responses dur[ill] surgery; a number of these cas[ill] would not have been identified if [ill] plasma cortisol response to exogen[ill] ACTH had been relied on. The obs[ill] vations that these patients did develop hypotension