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Table 2 Evaluating the utility of the insulin stress test (ITT), glucagon stimulation test (GST) and the short synacthen (corticotropin) test (SST)

From: How should we interrogate the hypothalamic-pituitary-adrenal axis in patients with suspected hypopituitarism?

Test Strengths Drawbacks
Insulin tolerance test 1. Very high sensitivity
2. Assessment of ACTH and GH axes
1. Requires experience and medical supervision
2. Labour intensive and time consuming
3. Contraindicated in ischemic heart disease and seizure disorders
4. Hypoglycaemia not always achieved
5. Unpleasant for patients
Glucagon stimulation test 1. Assessment of ACTH and GH axes
2. Can be used in cases where ITT is contra-indicated
1. Nausea in up to 30 % cases
2. False positive (fail) rate 8 %
3. Time consuming
Short synacthen (corticotropin) test 1. Simple and well tolerated
2. Can be used in cases where ITT is contraindicated
3. Reliably excludes clinically significant ACTH deficiency
1. Does not assess GH axis
2. Unreliable if recent pituitary insult e.g. surgery, apoplexy
3. Theoretical concerns of false negative (pass) rate (when compared with ITT)