Adrenocorticotropic Hormone Test
The pituitary gland produces the hormone ACTH, which stimulates the outer layer of the adrenal gland (the adrenal cortex). ACTH causes the release of the hormones hydrocortisone (cortisol), aldosterone, and androgen. The most important of these hormones released is cortisol. The ACTH test is used to determine if too much cortisol is being produced (Cushing's syndrome) or if not enough cortisol is being produced (Addison's disease).
ACTH has diurnal variation, meaning that the levels of this hormone vary according to the time of day. The highest levels occur in the morning hours. Testing for normal secretion, as well as for Cushing's disease, may require multiple samples. For sequential follow-up, a blood sample analyzed for ACTH should always be drawn at the same time each day.
ACTH can be directly measured by an analyzing method (immunoassay) in many large laboratories. However, smaller laboratories are usually not equipped to perform this test and they may need to send the blood sample to a larger laboratory. Because of this delay, results may take several days to obtain.
ACTH production is partly controlled by an area in the center of the brain (the hypothalamus) and partly controlled by the level of cortisol in the blood. When ACTH levels are too high, cortisol production increases to suppress ACTH release from the pituitary gland. If ACTH levels are too low, the hypothalamus produces corticotropin-releasing hormone (CRH) to stimulate the pituitary gland to make more ACTH. ACTH levels rise in response to stress, emotions, injury, infection, burns, surgery, and decreased blood pressure.
Cushing's syndrome is caused by an abnormally high level of circulating hydrocortisone. The high level may be the result of an adrenal gland tumor or enlargement of both adrenal glands due to a pituitary tumor. The high level of hydrocortisone may be the result of taking corticosteroid drugs for a long time. Corticosteroid drugs are widely used for inflammation in disorders like rheumatoid arthritis, inflammatory bowel disease, and asthma.
Addison's disease is a rare disorder in which symptoms are caused by a deficiency of hydrocortisone and aldosterone. The most common cause of this disease is an autoimmune disorder. The immune system normally fights foreign invaders in the body like bacteria. In an autoimmune disorder, the immune systems attacks the body. In this case, the immune system produces antibodies that attack the adrenal glands. Addison's disease generally progresses slowly, with symptoms developing gradually over months or years. However, acute episodes, called Addisonian crises, are brought on by infection, injury, or other stresses. Diagnosis is generally made if the patient fails to respond to an injection of ACTH, which normally stimulates the secretion of hydrocortisone.
A person's ACTH level is determined from a blood sample. The patient must fast from midnight until the test the next morning. This means that the patient cannot eat or drink anything after midnight except water. The patient must also avoid radioisotope scanning tests or recently administered radioisotopes prior to the blood test.
The risks associated with this test are minimal. They may include slight bleeding from the location where the blood was drawn. The patient may feel faint or lightheaded after the blood is drawn. Sometimes the patient may have an accumulation of blood under the puncture site (hematoma) after the test.
Each laboratory will have its own set of normal values for this test. The normal values can range from: Morning (4-8 A.M.) 8-100 pg/mL or 10-80 ng/L (SI units) Evening (8-10 P.M.) less than 50 pg/mL or less than 50 ng/L (SI units)
In Cushing's syndrome, high levels of ACTH may be caused by ACTH-producing tumors. These tumors may be either in the pituitary or in another area (like tumors from lung cancer or ovarian cancer). Low ACTH levels may be caused by adrenal enlargement due to high levels of cortisol and feedback to the pituitary.
In Addison's disease, high levels of ACTH may be caused by adrenal gland diseases. These diseases decrease adrenal hormones and the pituitary attempts to increase functioning. Low levels of ACTH may occur because of decreased pituitary function.
Jacobs, David S., et al. Laboratory Test Handbook. 4th ed. New York: Lexi-Comp Inc., 1996.
Pagana, Kathleen Deska. Mosby's Manual of Diagnostic and Laboratory Tests. St. Louis: Mosby, Inc., 1998.
Janis O. Flores
Adrenal glands—A pair of endocrine glands that lie on top of the kidneys.
Pituitary gland—The most important of the endocrine glands, glands that release hormones directly into the bloodstream; sometimes called the master gland.