Pharmacodynamic studies of nasal tetracosactide with salivary glucocorticoids for a noninvasive Short Synacthen Test

Context: The Short Synacthen Test (SST) is the gold standard for diagnosing adrenal insufficiency. It requires invasive administration of Synacthen, venous sampling, and is resource-intensive. Objective: To develop a nasally administered SST, with salivary glucocorticoids measurement, to assess the adrenal response. Design: We conducted 5 studies: 4 open-label, sequence-randomized, crossover, pharmacodynamic studies testing 6 doses/formulations and a repeatability study. Additionally, pharmacokinetic analysis was undertaken using our chosen formulation, 500 mu g tetracosactide with mucoadhesive chitosan, Nasacthin003, in our pediatric study. Setting: Adult and children's clinical research facilities. Participants: A total of 36 healthy adult males and 24 healthy children. Intervention: We administered all 6 nasal formulations using an European regulator endorsed atomization device. The IV comparators were 250 mu g or 1 mu g SST. Main Outcome Measures: We analyzed paired blood and saliva samples for plasma cortisol and salivary cortisol and cortisone. Results: The addition of chitosan to tetracosactide and dose escalation increased peak cortisol response (P = 0.01 and 0.001, respectively). The bioavailability of Nasacthin003 was 14.3%. There was no significant difference in plasma cortisol at 60 minutes between 500 mu g Nasacthin003 and 250 mu g IV Synacthen (P = 0.17). The repeatability coefficient at 60 minutes was 105 nmol/L for IV Synacthen and salivary cortisol and cortisone was 10.3 and 21.1 nmol/L, respectively. The glucocorticoid response in children was indistinguishable from that of adults. Conclusions: Nasal administration of Nasacthin003 generates equivalent plasma cortisol values to the 250-mu g IV SST and, with measurement at 60 minutes of salivary cortisol or cortisone, provides a noninvasive test for adrenal insufficiency.