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In response to Dr Pearlman's letter, three important points should be stressed that are subtly present in our report. First, a normal morning premetyrapone serum cortisol level indicates ACTH is available. Second, the fact that the serum cortisol level falls by more than 50% after metyrapone therapy indicates the circulating glucocorticosteriod is endogenous and not exogenous. Third, failure of plasma 11-deoxycortisol to increase significantly after metyrapone therapy shows there is an inadequate hypothalamic-pituitary-adrenal (HPA) axis reserve. Of the many metyrapone test results we obtained for our study, only a few showed all these facets.More simply, metyrapone testing is an appropriate measure of the function of the HPA axis and correlates well with other stressful and more hazardous tests (eg, insulin-induced hypoglycemia). Inability of a compromized HPA axis to respond to stress is therefore assumed by a positive metyrapone test.The patient in case 1 in our report
Carson TE. Long-Term Intramuscular Administration of Triamcinolone Acetonide-Reply. Arch Dermatol. 1976;112(9):1329. doi:10.1001/archderm.1976.01630330082040
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