Insulin tolerance test

An insulin tolerance test (ITT) is a medical diagnostic procedure

during which insulin is injected into a patient's vein to assess
pituitary function, adrenal function, and sometimes for other
purposes. An ITT is usually ordered and interpreted by
endocrinologists.
Insulin injections are intended to induce hypoglycemia. In response,
Adrenocorticotropic hormone (ACTH) and Growth Hormone (GH)
are released as a part of the stress mechanism. ACTH elevation
causes the adrenal cortex to release cortisol. Normally, both cortisol
and GH serve as Counterregulatory hormones, opposing the action
of insulin, i.e. acting against the hypoglycemia.
Thus ITT is considered to be a Gold standard for assessing the
integrity of the hypothalamo-pituitary-adrenal axis. Sometimes ITT
is performed to assess the peak adrenal capacity, e.g. before surgery.
It is assumed that the ability to respond to insulin induced
hypoglycemia translates into appropriate cortisol rise in the stressful
event of acute illness or major surgery.
This test is potentially very dangerous and must be undertaken with
great care. A health professional must attend it at all times.

Side Effects
Side effects include sweating, palpitations, loss of consciousness
and rarely convulsions due to severe hypoglycemia which may
cause coma. If extreme symptoms are present, glucose should be
given intravenously. In subjects with no adrenal reserve an
Addisonian crisis may occur. For cortisol stimulation, the ACTH
stimulation test has much less risk
Contraindications

 Age > 60 years

 This test should not be performed on children outside a specialist
pediatric endocrine unit
 Ischemic heart disease
 Epilepsy
 Severe panhypopituitarism, hypoadrenalism
 Hypothyroidism impairs the GH and cortisol response. Patients
should have corticosteroid replacement commenced prior to
thyroxine as the latter has been reported to precipitate an
Addisonian crisis with dual deficiency. If adrenal insufficiency is
confirmed, the need for a repeat ITT may need to be reconsidered
after 3 months thyroxine therapy.

Interpretation

The test cannot be interpreted unless hypoglycaemia (< 2.2 mmol/L)

is achieved.

Hypopituitarism
An adequate cortisol response is defined as a rise to greater than 550
nmol/L. Patients with impaired cortisol responses (less than 550 but
greater than 400 nmol/L) may only need steroid cover for major
illnesses or stresses. An adequate GH response occurs with an
absolute response exceeding 20 mU/L.

Cushing's syndrome
There will be a rise of less than 170 nmol/L above the fluctuations
of basal levels of cortisol.