What are the implications of a Dehydroepiandrosterone sulfate (DHEA-S) level of 392 and a morning cortisol level of 7.3?

Interpretation of DHEA-S 392 and Morning Cortisol 7.3

The DHEA-S level of 392 and morning cortisol of 7.3 suggest possible adrenal insufficiency that requires further evaluation with an ACTH stimulation test to confirm the diagnosis.

Understanding the Laboratory Values

Morning Cortisol

• A morning cortisol level of 7.3 μg/dL (assuming standard units) is in the low-normal range
• According to guidelines, a random cortisol >18 μg/dL in a stressed patient makes adrenal insufficiency unlikely, while levels <400 nmol/L (~14.5 μg/dL) with increased ACTH during illness raise strong suspicion of primary adrenal insufficiency 1
• This level is not definitively diagnostic but warrants further investigation

DHEA-S Level

• DHEA-S level of 392 μg/dL (assuming standard units) must be interpreted in the context of age and gender
• DHEA-S levels naturally decline with age in both sexes 2
• Low DHEA-S levels can be seen in patients with adrenal insufficiency, as the adrenal glands are responsible for DHEA production 3, 1

Diagnostic Approach

Confirmatory Testing Needed

• The diagnostic test for primary adrenal insufficiency should include paired measurement of serum cortisol and plasma ACTH 3
• An ACTH (cosyntropin) stimulation test is required for definitive diagnosis:
  • Normal response: peak cortisol ≥18 μg/dL and/or increment ≥9 μg/dL from baseline
  • In equivocal cases, a synacthen (tetracosactide) stimulated peak serum cortisol <500 nmol/L is diagnostic of primary adrenal insufficiency 3, 1

Differentiating Primary vs. Secondary Adrenal Insufficiency

Type	ACTH Level	Cortisol Level	Electrolytes
Primary	High	Low	↓Na, ↑K
Secondary	Low	Low	Normal

Clinical Implications

If Adrenal Insufficiency is Confirmed

1. Glucocorticoid Replacement:

   • Hydrocortisone 15-25 mg daily in divided doses 1
   • Dose adjustments based on clinical response

2. Mineralocorticoid Replacement (for primary adrenal insufficiency):

   • Fludrocortisone 0.1 mg daily 1
   • Monitor blood pressure, electrolytes for dose adjustments

3. DHEA Supplementation:

   • Consider for female patients with persistent lack of libido/energy despite optimized glucocorticoid and mineralocorticoid replacement
   • Dosage: 25-50 mg/day 1
   • Limited objective evidence of clinical benefit from large studies 3

Stress Dosing Education

• Double or triple usual daily dose for minor illness/stress
• Hydrocortisone 50-75 mg/day for moderate stress
• Hydrocortisone 100 mg IV immediately followed by 100-300 mg/day for severe stress 1

Important Precautions

Medication Interactions

• Avoid medications that interact with fludrocortisone:
  • Diuretics
  • Acetazolamide
  • NSAIDs
  • Carbenoxolone/licorice 3, 1

Patient Education

• All patients with confirmed adrenal insufficiency should:
  • Wear medical alert identification
  • Carry a steroid alert card
  • Receive education on stress dosing
  • Learn to recognize early symptoms of adrenal crisis 1

Monitoring

• Regular monitoring of:
  • Clinical status
  • Weight
  • Blood pressure
  • Electrolytes
  • Annual screening for associated autoimmune conditions 1

Conclusion

These laboratory values suggest possible adrenal insufficiency that requires further diagnostic evaluation. If confirmed, appropriate hormone replacement therapy and patient education are essential to prevent potentially life-threatening adrenal crisis.