— Discussion Can we harmonise clinical decision limits ?

Ronda Greaves Agenda - Information Collated

1) Background

2) RCPAQAP data (from 2016)

3) Kit inserts

4) Reference intervals

5) Questions JCTLM database

Certified Reference Material = 6

Reference Measurement Procedure

Reference Lab Pathway Annals of Clin Biochem 2017;54(3):308-322 CAH - 21OHase Deficiency Pharmacokinetics of cortisol replacement drugs

Hydrocortisone Well absorbed, Tmax=1 hour Half life 90-100 minutes (1.5 hours) Lasts for 6-8 hours Prednisolone Rapid and well absorbed (Tmax=1-2hrs) Half-life 2-4 hours Lasts for 10-20 hours Dexamethasone Half life 2.8-7.5 hours in 8-16 yr olds, up to 9.5 hours in <2 year olds Lasts for 15-36 hours, 48 hours in < 2 year olds

Slide provided by Dr Jeff Kao Micromedex database 2014 New Review Article

Annals of Clin Biochem 2017;54(3):308-322 Agenda - Information Collated

1) Background

2) RCPAQAP data (from 2016)

3) Kit inserts

4) Reference intervals

5) Questions RCPAQAP data – end of 2016

Target set using RMP

Instrument Abbreviation n Abbott A 35 Beckman B 13 Ortho O Roche R 47 Siemens S-C 24 Siemens S-I 9 Mass Spec MS 2 2016 Abbott 2016 Beckman 2016 Roche 2016 Siemens - 13 2016 Siemens - 20 2016 Sample Prep / LC-MS/MS Agenda - Information Collated

1) Background

2) RCPAQAP data (from 2016)

3) Kit inserts

4) Reference intervals

5) Questions Traceability

Vitros – “traceable to in-house reference calibrators which have been value assigned to correlate to samples measured by GC-MS”

Annals of Clin Biochem 2017;54(3):308-322 Cross-reactivity with cortisol v1

COBAS Electrochemiluminescence Immunoassay (ECLIA) For the antibody derivate used, the following cross- reactivities (%) were found: substance added per 10 μg/mL: cortisol-21-sulfate 0.04 0.30 dexamethasone 0.08 prednisone 0.28 substance added per 0.1 μg/mL: prednisolone 171 6-α-methylprednisolone 389 E.g. If a patient is taking prednisolone, then for every 0.1 mcg/mL of prednisolone, there is 171% cross-reactivity i.e. 0.17 ug/mL of the “cortisol” level is prednisolone Change to cortisol methods

20 RMIT University©2015 Changes to standardisation approach

Cortisol I

Cortisol II

21 RMIT 2015 Vietnam CPC University©2015 Cross Reactivity Table Instrument A B O R S-C S-I MS 11 beta hydroxyprogesterone 0.2 2.52 1 11 beta OH A 0 11 beta OH E 0 11 keto A 0 11 keto E 1.8 11-deoxycorticosterone 0 0.91 0.035 0.227 1.8 0 11-deoxycortisol 1.9 17.8 0.95 3.62 23.3 0 17 alpha OHP 0.6 5.33 0.553 0 1.2 0 Instrument A B O 17 OH pregnanoloneR 0.1S-C S-I 0 MS 20 alpha dihydrocortisol 0.5 20 alpha dihydrocortisone 0.2 11-deoxycorticosterone 0 0.91 0.03520 beta dihydrocortisol 0.227 1.8 1.3 0 20 beta dihydrocortisone 0 11-deoxycortisol 1.9 17.8 0.9521 deoxycortisol 3.62 23.3 0.515 8.1 0 0 6 beta OH cortisol 0.2 6.8 6-alpha-methylprednisolone 0.1 5.94 14.7 26.2 17 alpha OHP 0.6 5.33 0.553Aldosterone 0 0 1.2 0.3 0 0 allo-THF 6.5 17 OH 0.1 Alpha cortol 0 0 Alpha cortolone 0 0 0 21 deoxycortisol Beclomethasone 0.515 0 8.1 0 Beta cortol 0 0.006 0 6 beta OH cortisol 0.2 Beta cortolone 0 6.80 0 beta sitosterol 0 Betamethasone 0 6-alpha-methylprednisolone 0.1 5.94Budesonide 14.7 0 26.2 Canrenone 0.3 Cortisone 2.7 8.06 0.13Canrenone 4.68 0 31.1 0 0.9 2.08 1.03 1.29 5.3 8.6 cortisol 21 glucuronide 0.2 Dexamethasone 0 0.04 0.244Cortisone 02.7 8.06 0.20.13 4.68 31.1 0 0 Dehydrocorticosterone 1.9 Dexamethasone 0 0.04 0.244 0 0.2 0 Fludrocortisone 36.6 3.85DHEA 0 0 0.2 DHEAS 0 0 Prednisolone 12.3 23.92 26.8estradiol 7.32 0 109 49 0 0.006 0 0 0 Prednisone 0.6 3.05 0.076Fludrocortisone 2.3336.6 3.8534 0 5.90.2 Fluticasone 0 0 Medroxyprogesterone 0 Methotrexate 0 Methylprednisolone 21 Mornetasone 0 Prednisolone 12.3 23.92 26.8 7.32 109 49 Prednisone 0.6 3.05 0.076 2.33 34 5.9 0 0 0 0 0 0.5 0 0.46 0.459 0 0 0 Spirolactone 0 0 0 0 0.007 0.2 tetracycline 0 THE 0.1 0.3 0 THF 0.5 0.159 0 0.9 THS 0 Topiramate 0 Triamicinolone 0.5 0.022 Agenda - Information Collated

1) Background

2) RCPAQAP data (from 2016)

3) Kit inserts

4) Reference intervals

5) Questions 8am RI from package inserts

700

600

500

400 lower RI nmol/L Upper RI 300

200

100

0 Abbott Beckman Ortho Roche Siemens - C Siemens - I Mass Spec 8am cortisol RI

Package Insert RCPAQAP RI survey

n Low High A 0 B 1 140 640 O 1 172 497 R 14 142 539 S-C 3 220 660 S-I 1 100 540 RCPAQAP RI survey 2016

All labs Roche 800 700

700 600

600 500

500 400 Lower Low nmol/L nmol/L 400 Upper High 300 300

200 200

100 100

0 0 Published Adult LC-MS/MS RI LC-MS/MS Published RI

Male Female What does Graham say ?

http://www.sydpath.stvincents.com.au/spec_db/ 29 RMIT University© Clinical Biochemistry 1 Post Synacthen lower RI

Annals of Clin Biochem 2017;54(3):308-322 Agenda - Information Collated

1) Background

2) RCPAQAP data (from 2016)

3) Kit inserts

4) Reference intervals

5) Questions Questions

What are the areas we can agree on ? • Age • Gender • Instrument specific RI • Critical low level

Can we improve the traceability information in our kit inserts ?