COMPARISON BETWEEN THE SUPPRESSIVE EFFECTS OF DEXAMETHASONE AND LOPERAMIDE ON CORTISOL AND ACTH-SECRETION IN SOME PATHOLOGICAL CONDITIONS

Since in patients with Cushing's disease, unlike in normal subjects, tonic inhibitory opioid control of ACTH secretion does not operate, use of the opiate agonist loperamide (LOP) has recently been proposed in the diagnosis of hypercortisolemic states. We compared the sensitivity, specificity and diagnostic accuracy of the LOP test (16 mg orally) with corresponding results of the dexamethasone test (DXM, 1 mg orally overnight) in 23 normal subjects and in a total of 42 patients, affected by Cushing's disease (n=8), incidentally discovered adrenal masses with impaired function of the hypothalamic-pituitary-adrenal (HPA) axis (n=6), obesity (n=21) and depression (n=7). While in controls both DXM and LOP strongly suppressed plasma cortisol and ACTH, in Cushing's disease and in incidentalomas no patient showed a decrease in cortisol levels below 50 ng/ml or a reduction in plasma cortisol greater than 50% of basal values in response to LOP and DXM. In obese subjects both drugs significantly reduced plasma cortisol and ACTH without giving false positive results. In the depressed group only 3/7 patients showed a decrement in cortisol levels below 50 ng/ml after LOP in contrast to 6/7 after DXM. Thus, in patients with impairment of the HPA-axis, i.e. in Cushing's disease and in patients with adrenal incidentalomas and hormonal abnormalities, LOP and DXM test sensitivity was 100%. In controls and in obese patients specificity was 100% both with LOP and DXM, white in depressed patients it was 43% and 86% with LOP and DXM, respectively. In conclusion; since the diagnostic accuracy of the LOP test (94.9%) is slightly lower as compared to DXM (98.5%), use of loperamide gives no additional advantages in diagnosis of hypercortisolemic states. However, in account of its good specificity, the LOP test may be considered a complementary diagnostic procedure to DXM in pathological conditions such as obesity in which the DXM test may give false positive results.