Does Adrenaliv (generic name) interfere with cortisol level testing?

Does Adrenaliv Interfere with Cortisol Testing?

Yes, Adrenaliv can potentially interfere with cortisol testing, particularly when performing salivary cortisol measurements or when evaluating the hypothalamic-pituitary-adrenal axis function.

Mechanisms of Interference

Adrenaliv, like other medications that affect the stress response, can impact cortisol testing in several ways:

1. Direct impact on salivary biomarkers:

   • Physical and mental stressors, including medications that affect the stress response, can increase salivary cortisol and chromogranin A (CgA) levels 1
   • This can lead to falsely elevated cortisol readings, particularly in salivary testing

2. Diurnal variation interference:

   • Cortisol follows a diurnal pattern with highest levels in the morning and lowest at midnight
   • Medications that affect the stress response can disrupt this normal pattern, making interpretation of time-specific cortisol measurements difficult 1

Types of Cortisol Tests Affected

Different cortisol testing methods may be affected differently:

Salivary Cortisol Testing

• Most susceptible to interference from Adrenaliv
• Salivary cortisol is meant to reflect free cortisol levels but can be affected by medications 1
• The correlation between salivary cortisol and total serum cortisol can be disrupted by medications that alter stress response 1

Serum Cortisol Testing

• May be less affected than salivary testing, but still susceptible to interference
• Random plasma cortisol measurements show marked hourly variability (coefficient of variation 8-30%) even without medication effects 2

ACTH Stimulation Testing

• The high-dose (250-μg) ACTH stimulation test is the preferred diagnostic test for adrenal insufficiency 1
• Medications like Adrenaliv can potentially affect baseline cortisol levels prior to stimulation

Recommendations for Accurate Testing

To minimize interference when cortisol testing is needed:

1. Timing of medication and testing:

   • Ideally, temporarily discontinue Adrenaliv before testing if medically safe to do so
   • If discontinuation is not possible, document medication use when interpreting results

2. Test selection:

   • Use the high-dose (250-μg) ACTH stimulation test rather than the low-dose (1-μg) test for more reliable results 1
   • Consider measuring cortisol at 60 minutes post-ACTH administration, which has shown 99.7% concordance with traditional testing methods 3

3. Laboratory considerations:

   • Inform the laboratory about Adrenaliv use when submitting samples
   • Consider using total serum cortisol rather than salivary cortisol when medication interference is a concern 1

Special Considerations

• For patients with suspected Cushing syndrome, multiple testing methods may be required as no single test is perfect 1
• In critically ill patients, interpretation of cortisol testing is already challenging due to altered binding proteins and stress response; medication effects add further complexity 2
• Morning cortisol levels above 285 nmol/L generally exclude adrenal insufficiency with high sensitivity, while levels below 98 nmol/L strongly suggest it 4

When cortisol testing is essential for a patient on Adrenaliv, the high-dose ACTH stimulation test with measurement at 60 minutes provides the most reliable results with minimal interference.