Es Acthd Screening Criteria

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name: es-acthd-screening-criteria
description: This skill determines whether screening for adrenocorticotropic hormone deficiency (ACTHD) is indicated in childhood cancer survivors with hypothalamic‑pituitary axis radiation exposure between 24‑30 Gy. Screening is recommended when the survivor is >10 years post‑radiation or presents with clinical symptoms suggestive of adrenal insufficiency (e.g., fatigue, hypotension), triggered by questions such as “Should I screen for ACTHD in this survivor with 25 Gy radiation 12 years ago?” or “Does symptomatic adrenal insufficiency warrant ACTHD testing post‑moderate radiation?”
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# Assess ACTHD screening need based on radiation history

## STEP 1 — Gather Information
Collect radiation dose to hypothalamic‑pituitary axis (Gy), years since radiation, and presence of symptoms suggestive of ACTHD (fatigue, hypotension, hyponatremia, hyperkalemia, unexplained weight loss, etc.).

## STEP 2 — Rule In / Rule Out
Is the radiation dose between 24 Gy and 30 Gy (inclusive)? If no, screening for ACTHD is not indicated per this guideline (consider other etiologies). If yes, proceed to Step 3.

## STEP 3 — Classify or Stratify
Is the survivor >10 years post‑radiation OR reporting clinical symptoms suggestive of ACTHD? If yes, screening is indicated. If no, routine screening per this guideline is not indicated; reassess if symptoms develop or time passes.

## STEP 4 — Decide
If screening indicated, order a dynamic test for ACTHD (e.g., insulin tolerance test, low‑ or standard‑dose ACTH stimulation test) per guideline 6.3 (same as non‑cancer population). If not indicated, continue routine surveillance and re‑evaluate at next visit or if symptoms emerge.

## Clinical Guardrails / Mimics / Pitfalls
Do not rely on basal cortisol or ACTH levels alone; dynamic testing is required. Oral estrogen can raise cortisol‑binding globulin, elevating total cortisol while free cortisol remains normal. Consider mimics of fatigue/hypotension such as sepsis, dehydration, anemia, or other pituitary deficiencies (TSHD, GH deficiency). Avoid screening before 10 years post‑radiation unless symptoms appear, as ACTHD rarely manifests earlier.

## Concrete Clinical Example
A 16‑year‑old survivor of medulloblastoma received 25 Gy craniospinal radiation 12 years ago and now reports fatigue and orthostatic hypotension. Since dose is 25 Gy (within  (within 24‑30 Gy) and >10 years post‑radiation, screening for ACTHD is indicated; an insulin tolerance test is ordered.

**Source:** Hypothalamic Pituitary and Growth Disorders in Survivors of Childhood Cancer: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2018, DOI:10.1210/jc.2018-01175
> **TODO:** consider adding scripts/calc.py for the es-acthd-screening-criteria calculator