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CPE-008 · Scope and validity
AI-VAL-01: Cortisol result may be unreliable
Cortisol result may be unreliable. Evaluates sample drawn after 10 am OR estrogen/oral contraceptive/pregnancy (raises binding globulin) OR nephrotic syndrome, cirrhosis or critical illness (lowers binding globulin) OR exogenous glucocorticoid taken in the last 24 hours (prednisolone and hydrocortisone cross-react).
Condition
- sample drawn after 10 am OR estrogen/oral contraceptive/pregnancy (raises binding globulin) OR nephrotic syndrome, cirrhosis or critical illness (lowers binding globulin) OR exogenous glucocorticoid taken in the last 24 hours (prednisolone and hydrocortisone cross-react)
What it reports
- Total cortisol may mislead: the interpretation is provisional
Recommended next steps (for physician review)
- Repeat an 8 am cortisol with ACTH after the confounder is addressed, or use an ACTH-stimulation test
Diagnostic boundary
- Does not discard the value.
Evidence
- EV-ES-PAI-2016Bornstein SR, Allolio B, Arlt W, et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(2):364-389.Supports: Morning cortisol and ACTH as first tests; ACTH stimulation with 250 µg cosyntropin; peak cortisol below 18 µg/dL as insufficient Suspected adrenal crisis must be treated without waiting for tests
- EV-ES-GCAI-2024Beuschlein F, Else T, Bancos I, et al. European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and therapy of glucocorticoid-induced adrenal insufficiency. J Clin Endocrinol Metab. 2024;109(7):1657-1683.Supports: Glucocorticoid exposure by any route can suppress the axis; do not stop abruptly; cross-reactivity of prednisolone in cortisol assays
Cases where this rule fires
Open a case to see this rule fire with real inputs, then change the values until it stops.
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