Full Application for an Addition of a Test Categories in the EDL

Full application for an addition of a test categories in the EDL

Survey response 1

Response ID 54

Date submitted 2019-12-03 10:32:00

Last page 1

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1. Name of test category

Name of the test category addressed in the original submission: Cortisol (serum)

2. Pre-submission information

Please indicate your pre-submission response ID: [Pre-submission ID] 127

3. Applicant’s information (primary contact person):

Contact person, name and information of the person submitting the application: [LAST NAME, First name] SILVA, Carolina

Contact person, name and information of the person submitting the application: [Email address (...@....)] [email protected]

Contact person, name and information of the person submitting the application: [Phone number (+country code) phone number no spaces] +1-604-875-2117

Contact person, name and information of the person submitting the application: [Other information] -

4. Applicant’s information (secondary contact person):

[LAST NAME, First name] BARAKAUSKAS, Vilte

[Email address (...@....)] [email protected]

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[Phone number (+country code) phone number no spaces] +1-604-875-2345

[Other information] -

5. Details of the organization making the submission (if applicable)

Name of the organization making the submission (if applicable): [Name of the organisation] British Columbia Children’s Hospital

Name of the organization making the submission (if applicable): [Address]

Name of the organization making the submission (if applicable): [Department]

Name of the organization making the submission (if applicable): [Website] www.bcchildrens.ca

Name of the organization making the submission (if applicable): [Phone number]

6. Details of the organizations supporting the application:

Please provide up to three organizations supporting your application including a. Organization name, b. Contact person, c. Email address: Global Pediatric Endocrinology and Diabetes (GPED, www.globalpedendo.org)

7. Public health impact of the disease/condition:

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Please detail the public health relevance of conditions addressed with the proposed test and add references: Cortisol is the main glucocorticoid hormone produced by the adrenal gland. It is secreted in response to stimulation of the adrenal gland by corticotropin hormone (ACTH), produced by the pituitary. Determination of serum cortisol is relevant to the diagnosis of two groups of conditions: adrenal hypofunction (central and primary adrenal insufficiency) and adrenal hyperfunction (Cushing syndrome, of central or adrenal origin).

Adrenal hypofunction -- Adrenal insufficiency is characterized by insufficient secretion of cortisol. It is caused by either insufficient secretion of ACTH (central adrenal insufficiency) or by a non-functional adrenal gland (primary adrenal insufficiency, most commonly because of autoimmune destruction of the gland). The prevalence of central adrenal insufficiency is reported to be between 150-280/million, but is probably underestimated. It can be permanent (pituitary tumors, cranial injury from irradiation, surgery, trauma, infections) or transient (for weeks, months or even years, secondary to exogenous glucocorticoid withdrawal). This latter etiology has dramatically increased over the past decades. Glucocorticoids are largely used in general population worldwide (up to 2%), and adrenal insufficiency after discontinuation is not only common but usually unrecognized. There is no glucocorticoid administration form, dosing, treatment duration or underlying disease that could exclude the risk of transient adrenal insufficiency, although higher doses and longer use give the highest risk. In a meta analysis evaluating 3753 participants treated with corticosteroids for various conditions, the proportion of patients with adrenal insufficiency ranged from 4% for nasal administration to more than 50% for intra-articular administration. Stratified by disease, percentages ranged from slightly below 7% for asthma to 60% for hematological malignancies. The risk also varied according to dose and treatment duration. The prevalence of primary adrenal insufficiency (Addison’s disease) ranges between 82-144 cases per million. Autoimmunity is the most common cause in adults; other insults to the adrenal gland that lead to primary insufficiency include adrenal hemorrhage, cancer, infections (HIV, syphilis, tuberculosis, bacterial) and some medicines. Genetic causes, especially enzyme defects, are the most common cause in children. About half of pediatric cases can be attributed to congenital adrenal hyperplasia. Due to the diverse causes of adrenal insufficiency, no distinct group of individuals is at increased risk of disease. Cortisol is an essential hormone; its most important function is to help the body respond to stress, such as surgery and illness, and recover from infections. The hormone also helps maintain blood pressure and cardiovascular functions and regulates the metabolism of proteins, carbohydrates and fatty acids. Aldosterone plays a key role in sodium and potassium balance. Patients with adrenal insufficiency, both central and primary, often present with hypotension, anorexia, vomiting, weight loss, fatigue and recurrent abdominal pain. Reproductive complaints typically occur in women (amenorrhea, loss of libido, decreased axillary, and pubic hair). In addition, when there is primary adrenal insufficiency, hyperpigmentation and salt craving are usually present. Patients may also manifest neuropsychiatric signs and symptoms. In children, weight loss with failure to thrive as well as hypoglycemic crisis with seizures can be seen. Biochemical findings include hyponatraemia, hyperkalemia (for primary adrenal insufficiency) and hypoglycemia. Adrenal insufficiency is a life- threatening disorder which, if not recognized, can lead to very high morbidity and mortality. In patients with adrenal insufficiency, regardless of its cause, any type of stress can precipitate an adrenal crisis; the most frequent precipitating factors are gastrointestinal and other infectious diseases. Patients with adrenal crisis usually present with unexplained shock refractory to vasopressors and fluids. In different studies, the frequency of adrenal crisis has been reported to be between 6 and 8 per 100 patient-years and mortality rates, 0.5 per 100 patient-years. Early identification and treatment of adrenal crisis significantly improves mortality rates seen during these episodes. Well-informed patients with primary adrenal insufficiency (Addison's disease) undergoing currently accepted replacement therapy are considered to have a normal survival rate. However, studies still show that mortality of patients with adrenal insufficiency is 1.5-2-fold higher compared to the general population, particularly for patients diagnosed at a young age. Increased mortality in primary adrenal insufficiency is linked to adrenal crisis and sudden death; as well as cardiovascular, malignant, and infectious diseases. In addition to this, there is significant morbidity and impact on quality of life. A model for measurement of the health burden in patients with congenital adrenal hyperplasia estimated that for adults with this condition, adrenal crisis result in a loss of 7.3 years of life, or 9 quality-adjusted life-years (QALYs) on average.

Adrenal hyperfunction -- Cushing’s syndrome comprises a large group of signs and symptoms that reflect prolonged and inappropriately high exposure to glucocorticoids. The most common cause is iatrogenic, from medically prescribed corticosteroids. Endogenous Cushing can be caused by excess production of ACTH or by independent excessive production of cortisol by the adrenal gland. The reported total incidence of endogenous Cushing syndrome varies from 3 to 7 cases per million/year. However, estimates of the incidence of Cushing's syndrome are imprecise and likely underestimate the incidence of iatrogenic Cushing's, undiagnosed mild hypercortisolism, and ectopic ACTH syndrome. Thus, the incidence of Cushing's disease may be as high as 5 to 25 per million per year. The sex-related distribution of Cushing's syndrome varies with the cause. Men used to have a three times greater incidence of the ectopic ACTH syndrome, but the increasing incidence of lung cancer in cigarette-smoking women has narrowed that margin. Women are more likely than men to develop Cushing's disease, as well as either benign or malignant adrenal tumors. The age at presentation varies depending upon the cause of hypercortisolism. Incidence of ectopic ACTH syndrome increases rapidly after the age of 50 years, as lung cancer. Cushing's disease occurs mainly in women aged 25 to 45 years. Adrenal tumors have a bimodal age distribution, with small peaks in the first decade of life and major peaks at approximately 40- 50 years. Adrenal carcinoma is the cause of one-half of all cases of childhood Cushing's syndrome. Although Cushing’s syndrome is clinically unmistakable when full blown, the spectrum of clinical presentation is broad. Cushing's syndrome affects numerous systems, such as reproductive, dermatologic, metabolic, cardiovascular, musculoskeletal, neuropsychiatric, and infectious. Few, if any features of Cushing’s syndrome are unique, but some are more discriminatory than others, including reddish purple striae, plethora, proximal muscle weakness, easy bruising and unexplained osteoporosis. Other symptoms, such as fatigue, weight gain, depression, diabetes, hypertension, or menstrual irregularity are also common in individuals without the disorder, which makes the diagnosis really challenging. In children, weight gain with decreasing growth velocity are noticeable. This potentially lethal disorder page 3 / 17

is associated with significant comorbidities, including hypertension, diabetes, coagulopathy, cardiovascular disease, infections, and fractures. Studies showed that quality of life is significantly impaired, and it seems to improve after remission. Furthermore, improvement in quality of life appears to be significantly correlated with the degree of disease control. In addition to the considerable morbidity caused by hypercortisolism, there is also an increase in mortality rates with Cushing’s syndrome, which has shown to be higher in patients with untreated disease. The earliest reports of mortality documented a median survival of 5 years, with most deaths caused by vascular or infectious complications. However, with modern-day treatments, the standard mortality ratio after normalization of cortisol is similar to that of an age-matched population.

References: 1.Chabre O, Goichot B, Zenaty D, Bertherat J. Epidemiology of primary and secondary adrenal insufficiency: Prevalence and incidence, acute adrenal insufficiency, long-term morbidity and mortality. Ann Endocrinol (Paris). 2017 Dec;78(6):490-494. 2.Laureti S, Vecchi L, Santeusanio F, Falorni A. Is the prevalence of Addison's disease underestimated? J Clin Endocrinol Metab. 1999 May;84(5):1762. 3.Broersen LH, Pereira AM, Jørgensen JO, Dekkers OM. Adrenal insufficiency in corticosteroids use: systematic review and meta- analysis. J Clin Endocrinol Metab. 2015 Jun; 100(6):2171-80. 4.Dinsen S, Baslund B, Klose M, Rasmussen AK, Friis-Hansen L, Hilsted L, et al. Why glucocorticoid withdrawal may sometimes be as dangerous as the treatment itself. Eur J Intern Med. 2013 Dec;24(8):714-20. 5.Rushworth RL, Torpy DJ, Stratakis CA, Falhammar H. Adrenal Crises in Children: Perspectives and Research Directions. Horm Res Paediatr. 2018;89(5):341-351. 6.Meyer G, Badenhoop K. Addisonian Crisis - Risk Assessment and Appropriate Treatment. Dtsch. Med. Wochenschr. 2018 Mar;143(6):392-396. 7.Erichsen MM, Løvås K, Skinningsrud B, Wolff AB, Undlien DE, Svartberg J, et al. Clinical, immunological, and genetic features of autoimmune primary adrenal insufficiency: observations from a Norwegian registry. J Clin Endocrinol Metab. 2009 Dec;94(12):4882-90. 8.Hummel SR, Sadler S, Whitaker MJ, Ara RM, Dixon S, Ross RJ. A model for measuring the health burden of classic congenital adrenal hyperplasia in adults. Clin Endocrinol (Oxf). 2016 Sep;85(3):361-98. 9.Nieman LK, Biller BMK, Findling JW, Newell-Price J, Savage MO, Stewart PM et al. The Diagnosis of Cushing's Syndrome: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2008 May; 93(5): 1526–40. 10.Wengander S, Trimpou P, Papakokkinou E, Ragnarsson O. The incidence of endogenous Cushing’s syndrome in the modern era. Clin Endocrinol (Oxf). 2019 Aug;91(2):263-270. 11.Broder MS, Neary MP, Chang E, et al. Incidence of Cushing's syndrome and Cushing's disease in commercially-insured patients under 65 years old in the United States. Pituitary. 2015 Jun;18(3):283-9. 12.Steffensen C, Bak AM, Rubeck KZ, Jørgensen JO. Epidemiology of Cushing’s syndrome. Neuroendocrinology. 2010 Sep;92(1):1-5. 13.Lindholm J, Juul S, Jørgensen JO, Astrup J, Bjerre P, Feldt-Rasmussen U, et al. Incidence and late prognosis of cushing's syndrome: a population-based study. J Clin Endocrinol Metab. 2001 Jan; 86 (1):117-23. 14.Govindan R, Page N, Morgensztern D, Read W, Tierney R, Vlahiotis A, et al. Changing epidemiology of small-cell lung cancer in the United States over the last 30 years: analysis of the surveillance, epidemiologic, and end results database. J Clin Oncol. 2006 Oct 1;24(28):4539-44. 15.Milian M, Honegger J, Teufel P. et al. Tuebingen CD-25 is a sensitive tool to investigate health-related quality of life in Cushing’s disease patients in the course of the disease. Neuroendocrinology. 2013 Dec;98:188–99. 16.Webb SM, Ware JE, Forsythe A, Yang M, Badia X, Nelson LM et al.Treatment effectiveness of pasireotide on health-related quality of life in patients with Cushing's disease.Eur J Endocrinol. 2014 Jul;171(1):89-98. 17.Clayton RN, Jones PW, Reulen RC, Stewart PM, Hassan-Smith ZK, Ntali G et al. Mortality in patients with Cushing's disease more than 10 years after remission: a multicentre, multinational, retrospective cohort study. Lancet Diabetes Endocrinol. 2016 Jul;4(7):569-76. 18.Graversen D, Vestergaard P, Stochholm K, Gravholt CH, Jørgensen JO. Mortality in Cushing's syndrome: a systematic review and meta-analysis. Eur J Intern Med. 2012 Apr;23(3):278-82.

8. Potential public health impact of the test:

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Please explain in which way the proposed test benefits public health. Please detail your response and add references: Determination of serum cortisol is required for the diagnosis of both adrenal hypofunction and hyperfunction. It is also useful in screening for adrenal hypofunction in asymptomatic patients at high risk of developing adrenal insufficiency, including previous long-term exposure to exogenous corticosteroids, as well as pituitary tumors, pituitary surgery, history of cranial or total body irradiation. For epidemiology regarding these conditions, please refer to section 7. Recommendations for testing for adrenal insufficiency and Cushing’s syndrome are based on observational evidence of a large treatment effect on morbidity and mortality in patients diagnosed with the condition.

Adrenal hypofunction— As previously described, adrenal insufficiency is a life-threatening disorder which, if not recognized, can lead to very high morbidity and mortality. In patients with adrenal insufficiency, any type of infection or stress can precipitate an adrenal crisis, leading to unexplained, refractory shock with a high mortality rate. Treatment of adrenal insufficiency is relatively easy and affordable, using medicines included in the EML; it consists of glucocorticoid replacement, with hydrocortisone being the first choice, in two to three daily doses. Prednisone can also be used. Once-daily fludrocortisone is also given to patients with primary adrenal insufficiency. Appropriate treatment not only markedly decreases mortality, but it is also associated with significant improvements in quality of life. Generally, the prognosis is good for appropriately diagnosed and treated patients with adrenal insufficiency, who can have a normal lifespan, compared with the high mortality rate seen in untreated patients. The outstanding benefits of steroids for treating patients with adrenal insufficiency have been proven many decades ago. A multitude of case reports documented miraculous recovery in patients with Addison's disease who were treated with hydrocortisone in the 1930s. When congenital adrenal hyperplasia was discovered, chronic administration of hydrocortisone to these infants was found to reverse hypotension, hypoglycemia and salt wasting in the same dramatic manner as it did in Addison's disease. Current research is focused on finding different steroid formulations that can mimic the physiological circadian pattern of cortisol secretion, with less frequent dosing, in order to improve quality of life as well as compliance. Preventing adrenal crisis is of key importance. Mortality rate from crisis is reported at 0.5/100 patient years. To improve outcomes, timely diagnosis of patients with adrenal insufficiency who are at risk of developing this event as well as education to both patients and health professionals are required. Early treatment with parenteral hydrocortisone is life-saving and undoubtedly recommended by every expert guideline, for any patient with even suspected adrenal crisis. This medication is widely available and part of the EML. Adrenal hyperfunction Untreated, Cushing’s syndrome causes severe morbidity and mortality. Patients with active Cushing’s continue to have an increased mortality rate that is 1.7 to 4.8-fold greater than the general population. It is associated with significant comorbidities, including hypertension, diabetes, coagulopathy, cardiovascular disease, infections, and fractures. Treatment of patients with moderate to severe Cushing’s syndrome clearly reduces mortality and morbidity. Because Cushing’s syndrome tends to progress and severe hypercortisolism is probably associated with a worse outcome, it is likely that early recognition and treatment of mild disease would reduce the risk of residual morbidity. Even though morbidity and mortality rates decrease with treatment, these may be higher compared to the general population even after cure of hypercortisolism. In a recent meta-analysis of seven studies, patients with Cushing's disease in whom initial surgical cure was not obtained had excess mortality compared with the general population, while patients with initial remission did not. However, in a multicentre, retrospective cohort study, patients with Cushing's disease who have been in remission for more than 10 years still had an increased risk of overall mortality compared with the general population, particularly from circulatory disease, but median survival from cure was found to be excellent at about 40 years of remission.

References -- 1.Chabre O, Goichot B, Zenaty D, Bertherat J. Epidemiology of primary and secondary adrenal insufficiency: Prevalence and incidence, acute adrenal insufficiency, long-term morbidity and mortality. Ann Endocrinol (Paris). 2017 Dec;78(6):490-494. 2.Rushworth RL, Torpy DJ, Stratakis CA, Falhammar H. Adrenal Crises in Children: Perspectives and Research Directions. Horm Res Paediatr. 2018;89(5):341-351. 3.Rogoff M. Addison's disease: further report on treatment with "interrenalin" (adrenal cortical extract). JAMA. 1932 Oct;99(16):1309–15. 4.Meyer G, Badenhoop K. Addisonian Crisis - Risk Assessment and Appropriate Treatment. Dtsch. Med. Wochenschr. 2018 Mar;143(6):392-396. 5.Erichsen MM, Løvås K, Skinningsrud B, Wolff AB, Undlien DE, Svartberg J, et al. Clinical, immunological, and genetic features of autoimmune primary adrenal insufficiency: observations from a Norwegian registry. J Clin Endocrinol Metab. 2009 Dec;94(12):4882-90. 6.Hahner S, Spinnler C, Fassnacht M, Burger-Stritt S, Lang K, Milovanovic D et al. High incidence of adrenal crisis in educated patients with chronic adrenal insufficiency: a prospective study. J Clin Endocrinol Metab 2015 Feb;100 (2):407–16. 7.White K, Arlt W. Adrenal crisis in treated Addison's disease: a predictable but under-managed event. Eur J Endocrinol. 2010 Jan;162(1):115-20 8.Al Nofal A, Bancos I, Benkhadra K, Ospina NM, Javed A, Kapoor E et al. Glucocorticoid replacement regimens in chronic adrenal insufficiency: a systematic review and meta-analysis. Endocr Pract. 2017 Jan;23(1):17-31 9.Bornstein SR, Allolio B, Arlt W, Barthel A, Don-Wauchope A, Hammer GD, et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline.J Clin Endocrinol Metab. 2016 Feb; 101(2): 364–89. 10.Bergthorsdottir R1, Leonsson-Zachrisson M, Odén A, Johannsson G.Premature mortality in patients with Addison's disease: a population-based study. J Clin Endocrinol Metab. 2006 Dec;91(12):4849-53. 11.Nieman LK, Biller BMK, Findling JW, Hassan Murad M, Newell-Price J, Savage MO et al. Treatment of Cushing's Syndrome: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2015 Aug; 100(8):2807–31 12.Lindholm J, Juul S, Jørgensen JO, Astrup J, Bjerre P, Feldt-Rasmussen U, et al. Incidence and late prognosis of cushing's page 5 / 17

syndrome: a population-based study. J Clin Endocrinol Metab. 2001 Jan; 86 (1):117-23. 13.Clayton RN, Jones PW, Reulen RC, Stewart PM, Hassan-Smith ZK, Ntali G et al. Mortality in patients with Cushing's disease more than 10 years after remission: a multicentre, multinational, retrospective cohort study. Lancet Diabetes Endocrinol. 2016 Jul;4(7):569-76. 14.Graversen D, Vestergaard P, Stochholm K, Gravholt CH, Jørgensen JO. Mortality in Cushing's syndrome: a systematic review and meta-analysis. Eur J Intern Med. 2012 Apr;23(3):278-82.

9. Clinical utility of the proposed test/potential impact of the test on patient management and care

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Please provide your answer as described in the guidance document: Adrenal hypofunction -- For the diagnosis of adrenal insufficiency, depending on the availability of resources, two types of tests are used. First, early morning (7-8 am) cortisol levels: levels 500 nmol/L can be used to exclude the diagnosis of adrenal insufficiency with no need for further testing, some patients will have results in between 140 and 500 nmol/L and will need further testing to establish a clear diagnosis. Second, the so called ACTH-stimulation test, which consists on IV or IM administration of 250 mcg of cosyntropin, followed by determination of serum cortisol 30 or 60 minutes after the injection. Peak cortisol levels below 500 nmol/L or 18 mcg/dL, though assay dependent, at 30 or 60 minutes indicate adrenal insufficiency. In high income countries, the ACTH stimulation test is commonly used because it is independent of the time of the day, because cosyntropin is usually readily available and because there is no limit in the number of cortisol samples to be assessed. In low income countries, early morning cortisol determination will be preferred (see sections 10-13 for further details) The long-term treatment of adrenal insufficiency consists of exogenous corticosteroid replacement (both glucocorticoid and mineralocorticoid). For the treatment with glucocorticoids in these patients, consistent benefits on several outcomes have been demonstrated. Treatment with hydrocortisone in patients with hypocortisolism has been associated with significantly better scores for vitality, pain, general activity and mood. However, diagnosis should be confirmed to continue long-term treatment, as it could potentially lead to iatrogenic adrenal suppression and impaired stress response in patients with a previously normal function. In general, the replacement dose of glucocorticoid is aimed at replacing the missing cortisol or its equivalent. The average daily secretion rate of cortisol in normal subjects is 2.7 to 14 mg/m2/day. Society guidelines recommend replacement therapy with hydrocortisone (15–25 mg) or cortisone acetate (20–35 mg) in two or three divided oral doses per day. Since long-term treatment with a high replacement dose of glucocorticoids induces bone loss, this risk can be minimized by avoiding a higher substitution dose. Studies show that adult patients receiving 15 or 20 mg hydrocortisone/day feel nearly as well and content as normal healthy individuals. Higher frequency regimens and size-based dosing may be beneficial in individual cases. As an alternative to hydrocortisone, prednisolone or prednisone (3–5 mg/day), administered orally once or twice daily, can be used, especially in patients with reduced compliance. Though not widely available, new modified-release hydrocortisone treatments have been studied over the past few years. There is no role for hormonal measurements in adjusting glucocorticoid replacement treatment. This is done based on clinical parametres. Patients with adequate replacement have good energy levels and general well-being, maintain their body weight, do not have orthostatic changes on their blood pressure and have no signs of glucocorticoid excess on physical examination. In children, decreased growth velocity is an indirect sign of excess glucocorticoid therapy. Based on different studies, about one in 12 patients will experience a life-threatening adrenal crisis each year. To avoid fatal outcomes, adequate prevention and treatment of adrenal crisis is of highest importance. Parenteral hydrocortisone (intravenous or intramuscular) is given at a dose that ranges between 50 and 100 mg every 6 to 8 hours. Education for patients and relatives must include information about symptom awareness and increasing the glucocorticoid dosage in situations of stressors known to increase cortisol requirements. Patients should be equipped with a steroid card and glucocorticoid preparation for parenteral emergency administration. Mineralocorticoids are vital for maintaining water and electrolyte homeostasis, and thereby blood pressure. Patients with primary adrenal insufficiency, who have aldosterone deficiency, should receive mineralocorticoid replacement with fludrocortisone and not restrict their salt intake. Usual adult dose is 100 mcg daily. The WHO Essential Medicines list, 2019 includes hydrocortisone 5 mg, 10 mg and 20 mg tablets, as well as fludrocortisone 100 micrograms tablets. Prednisolone (5mg/ml solution and 5mg and 25 mg tablets) and parenteral hydrocortisone (powder for injection: 100 mg -as sodium succinate- in vial are also included under section 3 (antiallergics and medicines used in anaphylaxis) and section 8 (immunosuppressive medicines), although not specifically for the treatment of adrenal insufficiency.

Adrenal hyperfunction— The first step in the evaluation of patients for hypercortisolism is to exclude any exogenous causes of cortisol excess, such as administration of corticosteroid medications. After ruling out exogenous causes, the 2 most common options for screening for hypercortisolism include: midnight cortisol and the dexamethasone suppression test (which consists in measuring an early morning cortisol following administration of dexamethasone the night before). Tablets of dexamethasone are included in the 2019 WHO EML list under various sections. Urinary free and salivary cortisol are also mentioned as alternative tests for the diagnosis of Cushing’s. In low income countries, these tests are usually not readily available and the first 2 tests mentioned above are preferred. Overall, the evidence in adults indicates that performance is similar, so feasibility and technical aspects should be taken into account when choosing a test. Our application includes cortisol for the diagnosis of both adrenal hypo and hyperfunction. In low-resource settings, implementing only one test for the two conditions will be beneficial in terms of training, quality control, etc. Given the low incidence of Cushing’s disease and the fact that it can be properly diagnosed by measuring cortisol after a dexamethasone suppression test or overnight, we would not recommend including other tests to the EDL at the present time (see further information on the test in sections 10-13). The first choice treatment for Cushing’s syndrome is surgical resection of the underlying lesion/s (pituitary tumor, ectopic and adrenal adenoma or carcinoma). For pituitary tumors, adrenal adenomas or carcinomas, complete resection was associated with remission rates from 80% to nearly 100% and very high survival rates. Bilateral adrenalectomy for occult or metastatic ectopic ACTH-producing tumor can be a life-preserving emergency treatment in patients with very severe disease. The second choice treatment is medical therapy (ketoconazole), which is presently not included in the EML. Prompt treatment is important to reduce morbidity and mortality. Normalizing cortisol levels or its action allows to eliminate signs and symptoms and treat comorbidities associated with hypercortisolism. Normalization of cortisol leads to clinical and biochemical improvements regarding obesity, arterial hypertension, insulin resistance, glucose tolerance, dyslipidemia, bone mineral density, linear growth in children, cognition, psychiatric disorders, and health-related quality of life. After successful treatment, decreased body weight and fat mass, improved blood pressure, a reduction in antihypertensive treatment, or a reversal of hypertension usually occurs within weeks to a year. A longer duration of hypercortisolism is associated with persistent hypertension. Research indicates that the risk of infection is lower in patients with mild to moderate vs severe hypercortisolism. page 7 / 17

Bone mineral density and cognitive dysfunction improve after successful treatment of Cushing’s syndrome, but do not normalize in all patients. Additionally, quality of life improves after surgical treatment but remains below that of age and gender-matched subjects for up to 15 years. In addition to cortisol determinations, the availability of further tests to differentiate between primary and secondary causes for both adrenal insufficiency and Cushing’s disease, including hormonal, genetic and imaging studies, will differ. These tests do not represent an innovative technology.

References: 1.Bornstein SR, Allolio B, Arlt W, Barthel A, Don-Wauchope A, Hammer GD, et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline.J Clin Endocrinol Metab. 2016 Feb; 101(2): 364–89. 2.Johannsson G, Falorni A, Skrtic S, Lennernäs H, Quinkler M, Monson JP et al. Adrenal insufficiency: review of clinical outcomes with current glucocorticoid replacement therapy. Clin Endocrinol (Oxf). 2015 Jan;82(1):2-11. 3.Burger-Stritt S, Pulzer A, Hahner S. Quality of life and life expectancy in patients with adrenal insufficiency: what is true and what is urban myth? Front Horm Res. 2016 May;46:171-83. 4.Wichers M1, Springer W, Bidlingmaier F, Klingmüller D. The influence of hydrocortisone substitution on the quality of life and parameters of bone metabolism in patients with secondary hypocortisolism. Clin Endocrinol (Oxf). 1999 Jun;50(6):759-65. 5.Hahner S, Spinnler C, Fassnacht M, Burger-Stritt S, Lang K, Milovanovic D et al. High incidence of adrenal crisis in educated patients with chronic adrenal insufficiency: a prospective study. J Clin Endocrinol Metab 2015 Feb;100 (2):407–16. 6.White K, Arlt W. Adrenal crisis in treated Addison's disease: a predictable but under-managed event. Eur J Endocrinol. 2010 Jan;162(1):115-20 7.Bergthorsdottir R, Leonsson-Zachrisson M, Odén A, Johannsson G. Premature mortality in patients with Addison's disease: a population-based study. J Clin Endocrinol Metab. 2006 Dec;91(12):4849-53. 8.Puar TH, Stikkelbroeck NM, Smans LC, Zelissen PM, Hermus AR. Adrenal Crisis: Still a Deadly Event in the 21st Century. Am J Med. 2016 Mar;129(3):339.e1-9. 9.Nieman LK, Biller BMK, Findling JW, Hassan Murad M, Newell-Price J, Savage MO et al. Treatment of Cushing's Syndrome: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2015 Aug; 100(8):2807–31 10.Valassi E, Crespo I, Santos A, Webb SM. Clinical consequences of Cushing’s syndrome. Pituitary. 2012 Sep;15(3):319-29. 11.Clayton RN, Jones PW, Reulen RC, Stewart PM, Hassan-Smith ZK, Ntali G et al. Mortality in patients with Cushing’;s disease more than 10 years after remission: a multicentre, multinational, retrospective cohort study. Lancet Diabetes Endocrinol. 2016 Jul;4(7):569-76. 12.Graversen D, Vestergaard P, Stochholm K, Gravholt CH, Jørgensen JO. Mortality in Cushing's syndrome: a systematic review and meta-analysis. Eur J Intern Med. 2012 Apr;23(3):278-82. 13.Lindholm J, Juul S, Jørgensen JO, Astrup J, Bjerre P, Feldt-Rasmussen U, et al. Incidence and late prognosis of cushing's syndrome: a population-based study. J Clin Endocrinol Metab. 2001 Jan; 86 (1):117-23 14.Alexandraki KI, Grossman AB. Therapeutic Strategies for the Treatment of Severe Cushing's Syndrome. Drugs. 2016 Mar;76(4):447-58 15.Riedl M, Maier C, Zettinig G, Nowotny P, Schima W, Luger A. Long term control of hypercortisolism with fluconazole: case report and in vitro studies. Eur J Endocrinol. 2006 Apr;154(4):519-24 16.Canteros TM, De Miguel V, Fainstein-Day P. Fluconazole treatment in severe ectopic Cushing syndrome. Endocrinol Diabetes Metab Case Rep. 2019 Jul;2019(1):19-0020.

10. Systematic reviews of the clinical accuracy of the test

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Please describe or comment as requested in guidance document or state if no systematic review of clinical accuracy studies exists: Systematic reviews of serum/plasma cortisol assays were not identified. Reviews discussing the accuracy and sources of analytical bias or inaccuracy are included here, as well as comparing different diagnostic tests for the diagnosis of Cushing’s syndrome. We also include relevant non-systematic reviews.We also include relevant non-systematic reviews. Analytical (Method) Accuracy— Like all immunoassays, serum cortisol assays have some limitations. These include heterogeneity between assays made by different vendors, cross-reactivity with structurally similar compounds (which can be clinically significant when cortisol precursors or other steroid hormones are elevated, like in the case of congenital adrenal hyperplasia or metyrapone administration), in the presence of altered serum components or acute illness, and with altered protein binding (ex. In pregnancy and with OCP use) (Hawley 2016, see abstract in following section). Recognition of these limitations has led to some re-formulation of assays, and publications of inter-assay comparisons, providing end users with knowledge of the performance of the different assays on the market (Hawley 2016; El-Farhan 2017; Turpeinen 2013). While reference materials for cortisol exist, there are well documented differences between methods of analysis and immunoassay vendors themselves, attributed to differences in antibodies used as well the means of dissociating cortisol from its binding protein, CBG (Hawley 2016). Inter-assay variation can somewhat be mitigated through the use of laboratory- or method-specific cut-offs and through appropriate interpretative support of cortisol test results (Dickstein et al, 2008; Burgos 2019). Despite these limitations, serum cortisol measurement remains a key component of HPA axis assessment and management of patients with adrenal dysfunction.

Adrenal hypofunction-- For the ACTH stimulation tests, a meta-analysis evaluating the diagnostic accuracy of cortisol measurement in ambulatory subjects with presumed normal sleep-wake cycle following high-dose corticotropin stimulation (250 mcg dose) to identify HPA- insufficiency (defined relative to results of an insulin tolerance test or overnight metyrapone suppression test) demonstrated that 30 min post-dose cortisol values >833 nmol/L ruled out adrenal insufficiency (AI) and results < 440 nmol/L were highly predictive of AI, with an AUC of 0.82 (95% CI=0.78-0.86). Similarly, cortisol levels 30 min after a low-dose corticotropin stimulation (1 mcg dose) < 440 nmol/L and >600 nmol/L predicted AI or a normal reference test, respectively, with an AUC of 0.94 (95% CI=0.90-0.94) (Kazlauskaite, 2008). Use of the low-dose protocol in low-resource settings may not prove a disadvantage, as the low-dose protocol showed higher AUC or similar performance characteristics when compared with the high-dose protocol (Kazlauskaite 2008; Dorin et al. 2003). For screening, basal, fasting morning cortisol levels collected between 0800 and 1000 h of 365 nmol/L predicted normal HPA axis function with an AUC of 0.79 (95% CI=0.75-82) (Kazlauskaite, 2008).

Adrenal hyperfunction— Measurement of serum cortisol following overnight suppression with 1mg of dexamethasone has been reported to have sensitivities of >95% and specificities of 85-90% (Chiodini 2019). Meta-analysis comparing outcomes of an overnight dexamethasone suppression test to a reference standard for diagnosing Cushing syndrome (pathological diagnosis, response to therapy or clinical follow-up) yielded a pooled positive likelihood ratio of 11.6 (95% CI=5.8-23.1) and a negative LR of 0.09 (95% CI=0.05-0.14) (Elamin 2008). Among the tests evaluated, the authors concluded that urine free cortisol and the overnight dexamethasone suppression test have the most evidence supporting their use for detection of Cushing syndrome (Elmain 2008).

References: 1.El-Farhan N, Rees DA, Evans C. Measuring cortisol in serum, urine and saliva - are our assays good enough? Ann Clin Biochem. 2017 May;54(3):308-22. 2.Dickstein G, Saiegh L. Low-dose and high-dose adrenocorticotropin testing: indications and shortcomings. Curr Opin Endocrinol Diabetes Obes. 2008 Jun;15(3):244-9. 3.Burgos N, Ghayee HK, Singh-Ospina N. Pitfalls in the interpretation of the cosyntropin stimulation test for the diagnosis of adrenal insufficiency. Curr Opin Endocrinol Diabetes Obes. 2019 Jun;26(3):139-45 4.Turpeinen U, Hämäläinen E. Determination of cortisol in serum, saliva and urine. Best Pract Res Clin Endocrinol Metab. 2013 Dec;27(6):795-801 5.Kazlauskaite R, Evans AT, Villabona CV, Abdu TA, Ambrosi B, Atkinson AB et al. Corticotropin tests for hypothalamic-pituitary- adrenal insufficiency: a metaanalysis. J Clin Endocrinol Metab. 2008 Nov;93(11):4245-53. 6.Dorin RI, Qualls CR, Crapo LM. Diagnosis of adrenal insufficiency. Ann Intern Med. 2003 Aug; 139:194–204 7.Ng SM, Agwu JC, Dwan K. A systematic review and meta-analysis of Synacthen tests for assessing hypothalamic-pituitary- adrenal insufficiency in children. Arch Dis Child. 2016 Sep;101(9):847-53. 8.Elamin MB, Murad MH, Mullan R, Erickson D, Harris K, Nadeem S et al. Accuracy of diagnostic tests for Cushing’s syndrome: a systematic review and metaanalyses. J. Clin. Endocrinol. Metab. 2008 May;93(5):1553-62 9.Chiodini I, Ramos-Rivera A, Marcus AO, Yau H. Adrenal Hypercortisolism: A Closer Look at Screening, Diagnosis, and Important Considerations of Different Testing Modalities. J Endocr Soc. 2019 Apr 11;3(5):1097-1109.

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Please attach the reviews you make reference to: [{ "title":"","comment":"","size":"629.45","name":"2019-Chiodini_AdrenalTumorTests.pdf","filename":"fu_eiyfxfnae38r5wn","ext":"pdf" },{ "title":"","comment":"","size":"343.356","name":"2019-Burgos_ACTHstimPitfalls.pdf","filename":"fu_8m6byt4d5xt633r","ext":"pdf" },{ "title":"","comment":"","size":"202.05","name":"2013-Turpeinen_MethodReview.pdf","filename":"fu_kba2cxzh7yvc934","ext":"pdf" },{ "title":"","comment":"","size":"111.112","name":"2008-Dickstein_ACTHstim.pdf","filename":"fu_zw2ujq9awwzsf55","ext":"pdf" },{ "title":"","comment":"","size":"351.712","name":"2017-El-CortisolASsays.pdf","filename":"fu_w3vdg3a6h7ek64t","ext":"pdf" },{ "title":"","comment":"","size":"654.628","name":"2016-Ng_PedsReview.pdf","filename":"fu_c3gcvphq953a6x9","ext":"pdf" },{ "title":"","comment":"","size":"298.897","name":"2003-Dorin_CortisolStimRev.pdf","filename":"fu_ra9x2jt6snmv98u","ext":"pdf" },{ "ti tle":"","comment":"","size":"477.481","name":"2008-Kazlauskaite_StimTestMetaAnalysis.pdf","filename":"fu_546sq3pvez3zryj","ext ":"pdf" },{ "title":"","comment":"","size":"206.738","name":"2008-Elamin_Cushings.pdf","filename":"fu_q3e87gdcua5hx6h","ext":"pdf" }] filecount - Please attach the reviews you make reference to: 9

11. Primary studies of clinical accuracy of the test

Please describe or comment as requested in the guidance document or state if no primary studies of clinical accuracy are available: Method comparison studies representing data from common IVD vendors are included here. Studies comparing contemporary assays between multiple vendors and studies comparing immunoassays to mass spectrometry methods are included here. In addition, primary studies evaluating factors influencing cortisol test results are also included. References 1.Hawley JM, Owen LJ, Lockhart SJ, Monaghan PJ, Armston A, Chadwick CA et al. Serum cortisol: an up-to-date assessment of routine assay performance. Clin Chem. 2016 Sep;62(9):1220-9. 2.Vogeser M, Kratzsch J, Ju Bae Y, Bruegel M, Ceglarek U, Fiers T et al. Multicenter performance evaluation of a second generation cortisol assay. Clin Chem Lab Med. 2017 May 1;55(6):826-35 3.Kline GA, Buse, J, Krause RD Clinical Implications for Biochemical Diagnostic Thresholds of Adrenal Sufficiency Using a Highly Specific Cortisol Immunoassay. Clin Biochem. 2017 Jun;50(9):475-480. 4.Ortiz-Flores AE, Santacruz E, Jiménez-Mendiguchia L, García-Cano A, Nattero-Chávez L, Escobar-Morreale HF , et al. Role of sampling times and serum cortisol cut-off concentrations on the routine assessment of adrenal function using the standard cosyntropin test in an academic hospital from Spain: a retrospective chart review. BMJ Open. 2018; 8(5): e019273. 5.Peechakara S, Bena J, Clarke NJ, McPhaul MJ, Reitz RE, Weil RJ et al. Total and free cortisol levels during 1 μg, 25 μg, and 250 μg cosyntropin stimulation tests compared to insulin tolerance test: results of a randomized, prospective, pilot study. Endocrine. 2017 Sep;57(3):388-393. 6.Struja T, Briner L, Meier A, Kutz A, Mundwiler E, Huber A. Diagnostic Accuracy Of Basal Cortisol Level To Predict Adrenal Insufficiency In Cosyntropin Testing: Results From An Observational Cohort Study With 804 Patients. Endocr Pract. 2017 Aug;23(8):949-61. 7.Schmidt IL, Lahner H, Mann K, Petersenn S. Diagnosis of adrenal insufficiency: Evaluation of the corticotropin-releasing hormone test and basal serum cortisol in comparison to the insulin tolerance test in patients with hypothalamic-pituitary-adrenal disease. J Clin Endocrinol Metab. 2003 Sep;88(9):4193-8. 8.Montes-Villarreal J, Perez-Arredondo LA, Rodriguez-Gutierrez R, Gonzalez- Colmenero AD, Solis-Pacheco RC, González- González JG et al. Serum morning cortisol as a screening test for adrenal insufficiency. Endocr Pract [Internet]. 2019 Aug 28 [cited 2019 Sept 3]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31461355. 9.Tang TJ, Liu YP, Yu YR. Comparing overnight dexamethasone suppression test, urine free cortisol, and midnight serum cortisol for the initial diagnosis of Cushing' s syndrome. Sichuan Da Xue Xue Bao Yi Xue Ban. 2013 Sep;44(5):764-8. 10.Barrou Z, Guiban D, Maroufi A, Fournier C, Dugué MA, Luton JP et al.Overnight dexamethasone suppression test: comparison of plasma and salivary cortisol measurement for the screening of Cushing's syndrome.Eur J Endocrinol. 1996 Jan;134(1):93-6.

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Please attach the publications you make reference to: [{ "title":"","comment":"","size":"436.416","name":"2016-HAwley_CortisolAssayQuality.pdf","filename":"fu_ta4fyq24yrxbwtm","ext":"pd f" },{ "title":"","comment":"","size":"406.802","name":"2017-Vogesar- Cortisol2assay.pdf","filename":"fu_zuqh9u2g63z8iek","ext":"pdf" },{ "title":"","comment":"","size":"543.911","name":"2017-Kline_RocheIIassay.pdf","filename":"fu_6ptt8qx64z7c83b","ext":"pdf" },{ "title":"","comment":"","size":"1307.203","name":"2018-OrtesFlores- StimTestCutoff.pdf","filename":"fu_xfcyhcdrn45wz3w","ext":"pdf" },{ "title":"","comment":"","size":"75.981","name":"2017-Struja- BasalvsStimCort.pdf","filename":"fu_tbvz2eggv7cz7wn","ext":"pdf" },{ "title":"","comment":"","size":"471.721","name":"Peechakara2 017_Article_TotalAndFreeCortisolLevelsDuri%20%281%29.pdf","filename":"fu_7vznbg8bx6jikbk","ext":"pdf" },{ "title":"","comment ":"","size":"78.635","name":"2019-MontesVillarreal_abstractOnly.pdf","filename":"fu_2g286tf7mp9p68d","ext":"pdf" },{ "title":"","comment":"","size":"191.048","name":"2003-Schmidt-CRHtsts.pdf","filename":"fu_4pqq55eh5hn22fd","ext":"pdf" },{ "title":"","comment":"","size":"417.767","name":"barrou1996.pdf","filename":"fu_gapg7ib2c5kt4s7","ext":"pdf" }] filecount - Please attach the publications you make reference to: 9

12. Systematic reviews of the clinical utility/impact of the test on patient management and care

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Please describe any systematic reviews of studies on the impact of the test result in clinical practice on diagnosis, treatment and patient outcomes or state if none are available (please refer to the guidance document) Adrenal hypofunction-- Measurement of serum cortisol is required for the diagnosis of adrenal insufficiency, as previously stated, and therefore for its treatment. There are no modern studies comparing replacing therapy with no treatment, due to the proven life-threatening consequences of the latter. Treatment is guided by experts’ recommendation, aiming to mimic physiological secretion, both on a usual basis and in times of stress. There are also no randomized controlled studies evaluating glucocorticoid dose requirements in patients with adrenal insufficiency during times of increased cortisol need, and therefore the glucocorticoid doses recommended for the treatment of adrenal crisis are largely on an empirical basis. Glucocorticoid dose is typically based on the severity and duration of the stressor. Current recommendations places a higher value on the prevention of underdosage than on reducing potential negative effects of short-term overdosage, as there is no clear data on potential consequences of the latter, and undertreatment can have significant deleterious effects. One systematic review involving patients with either primary or adrenal insufficiency and Cushing's syndrome from any cause, showed that quality of life is reduced in both groups and it improves with treatment, although it is not completely reversed (Ho, 2018). Another recent systematic review on different glucocorticoids regimens showed some preliminary low-quality evidence of improved quality of life with new forms such as extended-/dual- release, and continuous subcutaneous forms. These studies could not demonstrate any relationship between glucocorticoid type and dose on detrimental effects on bone loss or rates of adrenal crisis (Al nofal, 2017). Due to the few systematic reviews available, we also include non-systematic reviews regarding the treatment of adrenal insufficiency. These reviews address the benefits of treatment with steroids, but also challenges, including finding the right dosing and frequency of administration, lack of complete resolution of morbidity, and issues in the developing world.

Adrenal hyperfunction— The following systematic reviews were performed regarding the treatment of Cushing’s syndrome. Measurement of serum cortisol is vital for the diagnosis of Cushing’s syndrome, and therefore for its treatment. A systematic review on endoscopic versus microscopic surgery for Cushing’s disease found remission rates of 80%, with either technique (with a tendency towards better results for macroadenomas with endoscopic procedure), and short term mortality below 0.5% (Broersen, 2018). Another study showed low quality evidence for benefits of microscopic transsphenoidal surgery, which provided remission rates ranging from 42 to 96% (median 77.9%), recurrence was 0–47.4% with a median of 11.5% (Petersen, 2015). A review on bilateral adrenalectomy showed adequate success with residual cortisol secretion ranging between 3-34% and less than 2% of relapse. Surgical morbidity was 18% and mortality 3%, but the latter increased to 17% on the 1st year after surgery, suggesting the need for improving postoperative care (Ritzel, 2013). A systematic review and meta-analysis on medical treatment for Cushing’s showed cortisol normalization effectively in a large percentage of patients, therefore supporting medical treatment for Cushing's disease patients a reasonable option when surgery is not available or non-curative. Therapy with multiple agents led to normal cortisol levels in up to 65% of patients (Broersen, 2018). Another review focusing on new drugs showed promising results regarding efficacy and safety data of current and emerging adrenal steroidogenesis inhibitors, that will have to be confirmed in larger-scale phase 3 studies (Fleseriu, 2016). Finally, another study showed that mortality in patients with Cushing’s disease remains increased even after initial biochemical cure remission. The hypothesis is that this is due to metabolic consequences of long-term overexposure to cortisol, which may provide support for early diagnosis and treatment (van Haalen, 2015).

References 1.Ho W, Druce M. Quality of life in patients with adrenal disease: A systematic review Clin Endocrinol (Oxf). 2018 Apr;89:119– 28 2.Al Nofal A, Bancos I, Benkhadra K, Ospina NM, Javed A, Kapoor E et al. Glucocorticoid replacement regimens in chronic adrenal insufficiency: a systematic review and meta-analysis. Endocr Pract. 2017 Jan;23(1):17-31 3.Johannsson G, Falorni A, Skrtic S, Lennernäs H, Quinkler M, Monson JP et al. Adrenal insufficiency: review of clinical outcomes with current glucocorticoid replacement therapy. Clin Endocrinol (Oxf). 2015 Jan;82(1):2-11 4.Puar TH, Stikkelbroeck NM, Smans LC, Zelissen PM, Hermus AR.Adrenal Crisis: Still a Deadly Event in the 21st Century. Am J Med. 2016 Mar;129(3):339.e1-9 5.Miller BS, Spencer SP, Geffner ME, Gourgari E, Lahoti A, Kambo MK et al. Emergency management of adrenal insufficiency in children: advocating for treatment options in outpatient and field settings. J Investig Med 2019 Feb;0:1–10 6.Coursin DB, Wood KE. Corticosteroid supplementation for adrenal insufficiency. JAMA. 2002 Jan 9;287(2):236-40 7.Crown A, Lightman S. Why is the management of glucocorticoid deficiency still controversial: a review of the literature. Clin Endocrinol (Oxf). 2005;63(5):483. 8.Khan U, Lakhani OJ. Management of Primary Adrenal Insufficiency: Review of Current Clinical Practice in a Developed and a Developing Country. Indian J Endocrinol Metab. 2017 Sep-Oct;21(5):781-783. 9.Johannsson G, Skrtic S, Lennernäs H, Quinkler M, Stewart PM. Improving outcomes in patients with adrenal insufficiency: a review of current and future treatments. Curr Med Res Opin. 2014 Sep;30(9):1833-47 10.Broersen LHA, Biermasz NR, van Furth WR, de Vries F, Verstegen MJT, Dekkers OM. Endoscopic vs. microscopic transsphenoidal surgery for Cushing's disease: a systematic review and meta-analysis. Pituitary. 2018 Oct;21(5):524-34 11.Petersenn S, Beckers A, Ferone D, van der Lely A, Bollerslev J, Boscaro M. Outcomes in patients with Cushing’s disease undergoing transsphenoidal surgery: systematic review assessing criteria used to define remission and recurrence. Eur J Endocrinol. 2015 Jun;172(6):R227-39 12.Ritzel K, Beuschlein F, Mickisch A, Osswald A, Schneider HJ, Schopohl J et al. Outcome of bilateral adrenalectomy in Cushing's syndrome: a systematic review. J Clin Endocrinol Metab. 2013 Oct;98(10):3939-48. 13.Broersen LHA, Jha M, Biermasz NR, Pereira AM, Dekkers OM. Effectiveness of medical treatment for Cushing's syndrome: a systematic review and meta-analysis. Pituitary. 2018 Dec;21(6):631-641 page 12 / 17

14.Fleseriu M, Castinetti F. Updates on the role of adrenal steroidogenesis inhibitors in Cushing's syndrome: a focus on novel therapies.Pituitary. 2016 Dec;19(6):643-653. 15.van Haalen FM, Broersen LH, Jorgensen JO, Pereira AM, Dekkers OM. Management of endocrine disease: Mortality remains increased in Cushing's disease despite biochemical remission: a systematic review and meta-analysis. Eur J Endocrinol. 2015 Apr;172(4):R143-9. Please attach the reviews you make reference to: [{ "title":"","comment":"","size":"1174.76","name":"broersen%20endoscopic%20vs%20microscopic%20surgery%20%281%29.pdf" ,"filename":"fu_kex893ktr3qdfuk","ext":"pdf" },{ "title":"","comment":"","size":"516.74","name":"fleseriu%20updates%20medical%20 treatment%20cushing.pdf","filename":"fu_jdipmgnx95t9mm8","ext":"pdf" },{ "title":"","comment":"","size":"620.46","name":"ritzel%2 0outcomes%20of%20bilateral%20adrenalectomy.pdf","filename":"fu_8vw4jm998xwcsm6","ext":"pdf" },{ "title":"","comment":"","siz e":"1174.76","name":"broersen%20endoscopic%20vs%20microscopic%20surgery.pdf","filename":"fu_74n5shfckk6r5ns","ext":"pd f" },{ "title":"","comment":"","size":"1440.592","name":"gc%20regimens%20in%20adrenal%20insufficiency.pdf","filename":"fu_ab68 sru8uwwhtp8","ext":"pdf" },{ "title":"","comment":"","size":"335.231","name":"%5B1479683X%20-%20European%20Journal%20of %20Endocrinology%5D%20THERAPY%20OF%20ENDOCRINE%20DISEASE_%20Outcomes%20in%20patients%20with%20 Cushing%27s%20disease%20undergoing%20transsphenoidal%20surgery_%20systematic%20review%20assessing%20criteria %20used%20to%20%281%29.pdf","filename":"fu_cyxnh6vfpeu22jf","ext":"pdf" },{ "title":"","comment":"","size":"175.567","name":" %5B1479683X%20-%20European%20Journal%20of%20Endocrinology%5D%20MANAGEMENT%20OF%20ENDOCRINE%20 DISEASE_%20Mortality%20remains%20increased%20in%20Cushing%27s%20disease%20despite%20biochemical%20remissi on_%20a%20systematic%20review%20and%20meta-analysis.pdf","filename":"fu_u5z7apnj26a7u2e","ext":"pdf" },{ "title":"","com ment":"","size":"500.633","name":"Ho_et_al-2018-Clinical_Endocrinology.pdf","filename":"fu_i2utnxf9z78iqmx","ext":"pdf" }] filecount - Please attach the reviews you make reference to: 8

13. Primary studies of the clinical utility/impact of the test on patient management and care

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Please briefly describe any primary studies of the clinical utility/impact of the test on patient management and care, or state if none are available (please refer to the guidance document): The most relevant studies were included. Adrenal hypofunction As previously explained, there are few studies evaluating the impact of treatment for adrenal insufficiency and adrenal crisis. It is considered standard practice and recommended by every clinical guideline. Current studies have been focusing on dosage and pharmacological forms that could be associated with less adverse effects and improve compliance. A small study on hydrocortisone doses for the treatment of secondary adrenal insufficiency showed that lower doses (15-20mg/day) had similar effects on well-being as higher doses, avoiding the risk of adverse bone health effects (Wichers, 1999). Another study showed benefits of 3-daily administrations of cortisone acetate in patients with primary adrenal insufficiency compared to and 2-daily dosing, with increased total UFC excretion and reduced plasma ACTH levels (Laureti, 2003). A study on steroid dose adjustment by weight or body surface area in patients with primary adrenal insufficiency showed benefits in terms of more physiological cortisol levels compared to fixed dose regimens (Mah, 2004). A study on oral dual-release hydrocortisone, showed benefits including more circadian-based serum cortisol profile and metabolic improvements in body weight, blood pressure and glucose metabolism (Johannsson, 2012). There are many studies on novel pharmacological forms of glucocorticoids for the treatment of adrenal insufficiency, which exceeds the aim of this submission. Adrenal hyperfunction A study on mortality and morbidity in Cushing’s disease, which also included a metaanalysis of previous reports, showed 2-fold increased mortality compared to the general population. However, patients in remission fare much better than those with persistence of hypercortisolism, and they appear not to have an increased mortality rate. Hypertension and diabetes mellitus are risk factors for worse outcome (Clayton, 2011). Similarly, another study on transphenoidal surgery for Cushing’s disease showed that successful treatment of Cushing's disease is associated with normal long-term survival, as opposed to those with initial persistent disease, supporting the need for early and aggressive intervention (Hammer, 2004). Another study on cardiovascular risk factors in patients with Cushing’s showed improvement of various parameters one year after remission, however, these were still abnormal compared with healthy controls (Faggiano, 2003). A small study on pediatric patients with Cushing disease, all of whom were cured with surgery (with or without radiotherapy), found that most of them achieved an adult height within target. Even though excess adiposity improved with treatment, it was still greater compared with the general population. (Davies, 2005) References 1.Wichers M, Springer W, Bidlingmaier F, Klingmüller D. The influence of hydrocortisone substitution on the quality of life and parameters of bone metabolism in patients with secondary hypocortisolism. Clin Endocrinol (Oxf). 1999 Jun;50(6):759-65. 2.Laureti S, Falorni A, Santeusanio F. Improvement of treatment of primary adrenal insufficiency by administration of cortisone acetate in three daily doses. J Endocrinol Invest. 2003 Nov;26(11):1071-5. 3.Mah PM, Jenkins RC, Rostami-Hodjegan A, Newell-Price J, Doane A, Ibbotson V et al. Weight-related dosing, timing and monitoring hydrocortisone replacement therapy in patients with adrenal insufficiency. Clin Endocrinol (Oxf). 2004 Sep;61(3):367-75. 4.Johannsson G, Nilsson AG, Bergthorsdottir R, Burman P, Dahlqvist P, Ekman B, et al. Improved cortisol exposure-time profile and outcome in patients with adrenal insufficiency: a prospective randomized trial of a novel hydrocortisone dual-release formulation. J Clin Endocrinol Metab. 2012 Feb;97(2):473-81 5.Clayton RN, Raskauskiene D, Reulen RC, Jones PW. Mortality and morbidity in Cushing's disease over 50 years in Stoke-on- Trent, UK: audit and meta-analysis of literature. J Clin Endocrinol Metab. 2011 Mar;96(3):632-42. 6.Hammer GD, Tyrrell JB, Lamborn KR, Applebury CB, Hannegan ET, Bell S. Transsphenoidal microsurgery for Cushing's disease: initial outcome and long-term results. J Clin Endocrinol Metab. 2004 Dec;89(12):6348-57. 7.Faggiano A, Pivonello R, Spiezia S, De Martino MC, Filippella M, Di Somma C et al. Cardiovascular Risk Factors and Common Carotid Artery Caliber and Stiffness in Patients with Cushing’s Disease during Active Disease and 1 Year after Disease Remission. J Clin Endocrinol Metab 2003; 88: 2527–33 Davies JH, Storr HL, Davies K, Monson JP, Besser GM, Afshar F et al. Final adult height and body mass index after cure of paediatric Cushing's disease. Clin Endocrinol (Oxf). 2005 Apr;62(4):466-72. Please include the articles/documents of key primary studies and all publications you make reference to: [{ "title":"","comment":"","size":"89.47","name":"laureti2003.pdf","filename":"fu_u2z8ajbm6spavtd","ext":"pdf" },{ "title":"","comment":"","size":"69.476","name":"wichers1999.pdf","filename":"fu_63acbugsvp3t24n","ext":"pdf" },{ "title":"","comment" :"","size":"386.124","name":"Johannsson%20hydrocortisone%20dual%20release.pdf","filename":"fu_jddb5cv72fqzfv7","ext":"pdf" },{ "title":"","comment":"","size":"248.856","name":"mah2004.pdf","filename":"fu_suf35c7fx5ewcim","ext":"pdf" },{ "title":"","comment":"","size":"191.324","name":"clayton2011.pdf","filename":"fu_getzysnqvzfqrzu","ext":"pdf" },{ "title":"","comment":"","size":"295.036","name":"hammer2004.pdf","filename":"fu_mw8mzqd93swk7g8","ext":"pdf" },{ "title":"","comment":"","size":"148.793","name":"davies2005.pdf","filename":"fu_sp4gk7x34eur5xe","ext":"pdf" },{ "title":"","comment":"","size":"201.4","name":"faggiano2003.pdf","filename":"fu_hs88ksmd8yknqrq","ext":"pdf" }] filecount - Please include the articles/documents of key primary studies and all publications you make reference to: 8

14. Details of any guideline recommendations concerning use of the test

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Briefly describe the specific recommendation (indicate where it can be found in the guideline) and summarise the evidence upon which it is based (indicating where it can be found in the evidence summaries): Adrenal hypofunction We include the Endocrine Society Clinical Practice guideline for the diagnosis and treatment of primary adrenal insufficiency, which recommends the standard dose IV corticotropin stimulation test over other existing diagnostics tests to establish the diagnosis of adrenal insufficiency. If a corticotropin stimulation test is not feasible, they suggest using a morning cortisol Please attach the guidelines that you are refering to: [{ "title":"","comment":"","size":"192.973","name":"addision%20disease%20aafp.pdf","filename":"fu_jw9rhs6thjfi846","ext":"pdf" },{ " title":"","comment":"","size":"1178.201","name":"adrenal%20insufficiency%20pediatrics%20in%20review.pdf","filename":"fu_f6d8x nxjekjfuev","ext":"pdf" },{ "title":"","comment":"","size":"2712.89","name":"emergency%20management%20of%20adrenal%20crisis. pdf","filename":"fu_ubr8gke8x3gegc7","ext":"pdf" },{ "title":"","comment":"","size":"464.027","name":"Husebye_et_al-2014-Journal_ of_Internal_Medicine.pdf","filename":"fu_mr8j9a8e2u9gmed","ext":"pdf" },{ "title":"","comment":"","size":"280.377","name":"jcem03 64%20clinical%20practice%20guideline%20adrenal%20insufficiency.pdf","filename":"fu_jg8wwu8rit279bm","ext":"pdf" },{ "title":"" ,"comment":"","size":"151.617","name":"consenso%20mexicano%20cushing.pdf","filename":"fu_6cpy7n5wxgpsrxv","ext":"pdf" },{ " title":"","comment":"","size":"211.368","name":"diagnosis%20of%20cushing%202008.pdf","filename":"fu_229synqn84nuc2i","ext":" pdf" },{ "title":"","comment":"","size":"692.185","name":"cushing%27s%20syndrome%20review.pdf","filename":"fu_89pt2p9zzrusee g","ext":"pdf" },{ "title":"","comment":"","size":"599.354","name":"chiodini%20adrenal%20hypercortisolism.pdf","filename":"fu_h59db i2fcngrz2z","ext":"pdf" },{ "title":"","comment":"","size":"954.885","name":"cushing%20pediatrics%20in%20review.pdf","filename":"f u_ahvfg82bdt5jnym","ext":"pdf" }] filecount - Please attach the guidelines that you are refering to: 10

15. Examples of commercially available IVD products in the proposed new category

Please download and complete the table in Annex I with commercially available IVD products in the test category, and include the information listed for each one. Please upload the completed file back and all the relevant test Instructions For Use (Package Inserts): [] filecount - Please download and complete the table in Annex I with commercially available IVD products in the test category, and include the information listed for each one. Please upload the completed file back and all the relevant test Instructions For Use (Package Inserts): 0

16. Training requirements

Considering the tests mentioned in 15 above, what in general are the training requirements?: Significant training required

17. Equipment required

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Considering the tests mentioned in 15 above, please describe in general terms what, if any, equipment is required other than that provided with the test: Individuals performing testing need to be familiar with how to operate the immunoassay instrument, how to ensure the assay is performing adequately (ex. Performing Quality Control, routine instrument maintenance, familiarity with instrument and method error codes, ability to troubleshoot). In North America this equates to skills associated with personnel trained and certified as Medical Lab Technologists. Instrument-specific training is usually conducted by the vendor, and may include on-site training for a super-user who is then capable of providing one-day/on the job training to other staff in the laboratory. As with all immunoassays, users need to be familiar with assay limitations, specific to each vendor, including but not limited to: specimen handling, processing and stability; interferences such as hemolysis, lipemia, icterus, biotin, heterophile antibodies, exogenous or endogenous steroid hormones and medications; whether sample dilution is a permitted/compatible means of extending the analytical measuring interval; physiological factors affecting the test result including diurnal variation and cortisol-binding protein levels. Regarding specific equipment required: - Refrigerators for reagent and possibly sample storage. - Freezers to store calibrator and QC material, and samples for prolonged storage. - Class A pipettes are generally required if calibrator reconstitution is needed. - Distilled water will be needed when reagents, calibrators or quality control must be reconstituted. - Centrifuges are needed for sample processing as this is a serum/plasma test. Use of high-purity water (such as Distilled or Type A) is essential for correct reagent preparation and test function. While several manufacturers include urine as an acceptable sample type, most require pre-extraction of the sample with an organic solvent. The extraction procedure, in many laboratories, is considered a complex sample processing step and also requires high-grade solvents, glass test tubes, special dry-down apparatus, fume hood ventilation and safe disposal of chemical waste, making the analysis of urine cortisol logistically challenging in resource-limited settings. As our recommendations involve serum/plasma cortisol testing, materials associated with urine cortisol analysis are not discussed in this application. Other tests already included in the EDL, such as TSH and troponin, are also measured with immunoassays. The same analyzers could be used for the measurement of cortisol, without the need for new equipment.

18. Energy requirements

Considering the tests mentioned in 15 above, what, if any energy source is required for performance of the tests?: Other

Considering the tests mentioned in 15 above, what, if any energy source is required for performance of the tests?: [Other] Continuous electrical power during instrument operation. If reagents are to be left onboard the instrument, power may need to be continuous while instrument is not testing samples to maintain reagent viability.

19. Landscape reviews

Please list any landscape reviews describing the different test technologies and their use or state if none available: Non available

Please attach the documents refered to in this question:

filecount - Please attach the documents refered to in this question: 0

20. Cost and Cost-effectiveness

Please provide a summary of data on comparative cost and cost-effectiveness or state if not available: N/A. It should be emphasized that the cost of a test will depend on many factors, e.g. on the availability of a company in the country, the salary of technical staff on the negotiations between the ministry of health and the company. In British Columbia, the MInistry of Health reimburses 13.29 $ CAD for a cortisol determination.

21. Ethical issues

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Please detail any important ethical considerations related to the proposed test category and any consequences of its use: Often, patients have a number of features that are caused by cortisol excess but that are also common in the general population, such as obesity, depression, diabetes, hypertension, or menstrual irregularity. As a result, there is an overlap in the clinical presentation of individuals with and without the disorder. Similarly, some non-specific symptoms of adrenal insufficiency, particularly fatigue, can be experienced by healthy individuals. It is important that these tests are adequately ordered and interpreted by experienced professionals, in order to avoid unnecessary further studies and visits and increased costs. The availability of laboratory studies to diagnose adrenal insufficiency should not prevent from starting prompt therapy in an acutely ill patient with possible adrenal crisis. Acute adrenal insufficiency is a life-threatening condition, and, if clinically suspected, acute emergency treatment should be initiated with no delay. If cortisol levels are measured and ACTH stimulation test is not available, given the life-threatening consequences of untreated adrenal insufficiency, providing steroid replacement therapy and stress dosing to all patients with low or borderline-normal morning cortisol levels is the safest and recommended approach. As for Cushing’s disease, given the relatively low prevalence of this disease, testing should not be performed unless it is based on reasonable clinical suspicion. Wider availability of this diagnostic test should not lead to unnecessary testing; false-positive results, with their attendant costs, are reduced if case detection is limited to individuals with an increased pretest probability of having the disorder.

22. Equity and human rights issues

Please indicate if it reduces inequities and increases accessibility or if the test may prove inaccessible to some populations: Adrenal hypofunction If the test becomes available, it should reduce inequity, especially in resource-limited settings, by helping diagnose adrenal insufficiency and providing steroid replacement therapy and stress dosing in a timely manner to those who need them, and preventing their misuse in patients with preserved adrenal function. Adrenal hyperfunction Cosyntropin is currently not available in many low-income settings. Should this test be added to the EDL, an application for inclusion of this diagnostic agent for the next EML revision might need to be considered.

Signature

Through the electronic signature below, I acknowledge that I have provided appropriate information to support this submission. I acknowledge that WHO reserves the right to format and select the information provided as necessary and agree that the information will be publicly disclosed by WHO. [Electronic Signature (type your full name to sign):] Carolina Silva

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