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Long-term intramuscular administration of triamcinolone acetonide.

To the Editor.— In their article ( Arch Dermatol 111:1585, 1975), Carson et al erred when they used the metyrapone test to assess hypothalamic-pituitaryadrenal (HPA) axis responsiveness to "stress" in patients still receiving triamcinolone acetonide therapy intramuscularly. "Certain precautions should be taken in a metyrapone test. First, the patient should not simultaneously receive drugs that suppress ACTH secretion (exogenous glucocorticosteroids). . . ." 1 That is, the metyrapone test seeks to create "stress" by blocking the endogenous production of cortisol, thus creating a deficiency in circulating glucocorticosteroids. Then the normal HPA axis response is to sense the deficiency, increase the release of ACTH, and, ultimately, increase measurable plasma 11-deoxycortisol. However, if the patient is already receiving significant doses of triamcinolone acetonide, no deficiency can develop and hence no "stress" can occur because metyrapone has no effect on exogenous circulating glucocorticosteroids. Therefore, in the patient receiving treatment, the HPA axis will fail to respond, not