The future of cortisol testing

We recently welcomed Professor Miguel Debono, consultant endocrinologist and clinical director of diabetes and endocrinology at Sheffield Teaching Hospitals, to discuss his research into the use of saliva rather than blood in cortisol testing.

Why do we test cortisol?

Cortisol is tested when there is a suspicion someone is producing too much or too little cortisol. When low cortisol is suspected, cortisol will be measured at the peak of natural cortisol production, usually first thing in the morning. When high cortisol is suspected, cortisol may be measured at night, as this is the lowest point of natural cortisol production.

The most common method for testing cortisol is a blood (serum) cortisol test. This test takes place in the morning in hospital.

Professor Debono’s research instead makes a clinical case for the use of saliva as a method for testing cortisol.

Advantages of salivary cortisone testing

The salivary cortisone test takes place at home and patients will provide their own saliva sample. This is a much less invasive approach to traditional blood tests, with no needles involved.

To take a saliva test using a salivette, adult patients will chew a swab for around a minute, then package up the swab and return this to the endocrine clinic by post. The test can stay stable for up to five days, meaning the results will still be accurate when they reach the clinic even if there are some delays in the post.

The saliva test takes place in familiar surroundings and avoids the additional stress of being in a hospital environment. The stress of travelling to and being in hospital can cause higher stress levels in many people, which can affect the results of a cortisol tests. 80% of patients in Professor Debono’s clinic preferred taking the test at home.

The salivary cortisone test is very low cost. The hospital-based blood test costs around £398 per test, whereas the postal saliva test costs £20 per test. The deduction in cost could see estimated national savings of £24 million per year.

The deduction in cost could see estimated national savings of £24 million per year.

Why does spit work as well as blood?

The results of salivary cortisone tests are very accurate. In a recent study, Professor Debono identified 115 patients without adrenal insufficiency and 89 with adrenal insufficiency using saliva cortisone tests. These patients had participated in the previous NIHR-funded diagnostic accuracy study in 2020. Five years later, none of the 115 patients without adrenal insufficiency had developed adrenal insufficiency, showing the test was accurate initially.

Saliva cortisone testing can also be used to detect too much cortisol and diagnose Cushing’s disease. Using late night at home testing, the saliva cortisone test was 100% sensitive.

Using late night at home testing, the saliva cortisone test was 100% sensitive.

Key takeaways:

Patients with pituitary lesions are at risk of developing adrenal insufficiency and should be screened
Waking salivary cortisone is an accurate, evidence-based screening test for adrenal insufficiency
Midnight saliva testing also helps screen for Cushing's disease, and to check for its return after treatment.
Home saliva testing is cheaper than hospital testing and patients consistently prefer it.

Questions from the audience

Could saliva cortisol or cortisone testing be used to help optimise the timing of hydrocortisone replacement therapy?

Yes. Here's a more cohesive and logically ordered set of questions that you could ask an endocrinologist or researcher: In most circumstances we would not usually recommend measuring cortisol to optimise hydrocortisone replacement treatment but if needed saliva cortisone not cortisol can be used.

Could saliva cortisol or cortisone testing eventually be introduced in GP care to help identify possible endocrine disorders earlier, before referral to an endocrinologist?

Yes, eventually when resources are available GPs will be able to request this test to help identify endocrine disorders.

If testing is currently limited to specialist laboratories, how likely is it that saliva cortisone testing will become more widely available across NHS hospitals in the future?

At present, NHS trusts can request waking salivary cortisone testing and send samples to a central laboratory for analysis. Over time, individual trusts may establish their own local laboratory assays for measuring cortisone in saliva, provided they are satisfied that the analytical method is sufficiently accurate, reliable and cost-effective. This approach would allow trusts to develop local testing capacity while maintaining appropriate standards of quality and clinical governance.

More broadly, how do you see saliva-based testing changing the diagnosis and management of adrenal and pituitary disorders over the next 5 to 10 years?

We are currently undertaking an NIHR-funded Health and Social Care Delivery Research study to establish the processes required to implement waking salivary cortisone testing across NHS trusts. The findings will provide a practical framework that can be used by NHS trusts to establish saliva testing pathways for the investigation of adrenal and pituitary disorders. Given that saliva testing for cortisone is accurate, offers significant benefits to patients, and has the potential to reduce healthcare costs, we anticipate that its use will become increasingly widespread across the NHS over the coming years.

People with adrenal insufficiency face life-threatening emergencies called adrenal crises, which need urgent treatment with hydrocortisone injections. In this study, 12 people shared their struggles of managing their AI and adrenal crises, which included complex injection procedures, severe symptoms which made self-injection challenging, and limited support to manage these crises effectively.

The study identified several areas that would help people to self-manage their AI better. This included:

Simpler injection devices
Better information
Improved training for healthcare staff

Implementing these suggestions would help prevent avoidable hospital admissions and save lives.

Click here to read the full article. This article was written by Aldons Chua, an Endocrine Specialist Nurse and a member of our staff team.

For more information on what to do in an emergency adrenal crisis situation, please see our Emergency Info for AI and AVP-D page.

Adrenal crisis is a life-threatening situation where a person’s cortisol level has significantly dropped. It requires urgent medical treatment. For patient's who may be at risk of experiencing adrenal crisis, there can be lots of worry around whether healthcare professionals will recognise and know how to properly treat your condition.

At The Pituitary Foundation, we aim to provide educational and supportive resources to help you feel empowered to receive the medical care you need. As part of this, we recently delivered a talk on patient self-advocacy, with a particular focus on adrenal insufficiency and adrenal crisis.

In this talk, Professor John Wass (Professor of Endocrinology) provides his practical tips for preparing for healthcare appointments, to ensure you get the most out of them. He also discusses what to do if you feel you are not receiving, or have not received, adequate care while attending A&E with signs of adrenal crisis.

You can Prof Wass' full talk below.

In his talk, Prof Wass also mentions a research paper that he continually refers to when discussing adrenal crisis and how this should be handled by healthcare professionals. This paper can be a useful tool for educating healthcare professionals on what adrenal crisis is and how they should manage patients who present with symptoms.

You may wish to download and print this paper and bring it with you to future healthcare appointments or visits to A&E.

BMJ article_How to avoid precipitating an acute adrenal crisis Download

In the video below, our endocrine specialist nurse, Darshna Patel, covers how to adjust your hydrocortisone doses during periods of illness or physical strain. She goes through the 'Sick Day Rules' for managing hydrocortisone medication, as well as the signs of adrenal crisis and what to do if this occurs.

You can watch this video for a helpful reminder of the Sick Day Rules, or share it with others to educate them.

This year, Ramadan is expected to start on the evening of Friday 28th February 2025 and take place until Sunday 30th March 2025. It is a time of fasting, reflection, prayer and community for Muslims around the world.

If you are affected by a pituitary condition and are wanting to fast during Ramadan, it is important to speak to your GP or healthcare provider beforehand, to be sure that you can do this safely. Our leaflet, Fasting with Adrenal Insufficiency, provides useful information to help you observe Ramadan safely if you have adrenal insufficiency.

This leaflet is endorsed by the Society for Endocrinology, and was created in collaboration with Addison’s Disease Self-Help Group and Living With CAH. It is also included in the British Islamic Medical Association (BIMA) Ramadan Compendium.

Please note, this leaflet is for informational purposes only and does not replace advice given by your GP or healthcare provider. If you have any questions or concerns about how you can fast safely with adrenal insufficiency, you should seek advice from your GP or endocrinology team.

Fasting With Adrenal Insufficiency Leaflet (Print Colour)_New logo Download

There have been a few updates to the sick day rules for those with adrenal insufficiency recently. We have been getting a few questions and want to clear things up.

The Society for Endocrinology (SfE) have recently changed their guidance. We will be updating our sick day rules on the website and within our adrenal insufficiency booklet in accordance with the new guidelines as soon as possible.

It will cause no harm to follow either our existing sick day rules, or the rules your clinic has provided, or the new SfE rules for now.

We will be continuing our advocacy work with the SfE and other support organisations to ensure that the guidelines are consistent and clear.