The use of theophylline as an in vivo probe of adrenocortical function

The first step in the stimulatory action of most polypeptide hormones, including ACTH, is interaction with a specific target organ plasma membrane receptor. Theophylline, a nonspecific stimulus of several endocrine processes, does so presumably by circumventing the receptor step and directly increasing cAMP by inhibiting phosphodiesterase-mediated hydrolysis. Five patients with adrenal insufficiency, documented by a lack of cortisol secretion in response to exogenous ACTH, underwent a 4-h iv infusion of theophylline. In three of the five individuals, a significant concentration of cortisol was measured in serum for the first time. The patients who responded included one patient with the syndrome of ACTH insensitivity, one with ACTH deficiency, and one with idiopathic primary adrenal failure. Two patients with autoimmune adrenalitis failed to respond to theophylline, although one was tested very early in the course of her disease. We also noted that theophylline stimulated renin secretion and, in one patient with an intact zona glomerulosa, evoked a secondary rise in aldosterone equal to that produced by diuresis and upright posture. These studies suggest that the preservation of cortisol responsiveness to theophylline, after the loss of sensitivity to ACTH, may be relate to either the duration of the adrenal insufficiency or to the etiological mechanism. Patients with autoimmune adrenalitis may undergo more rapid and complete adrenocortical destruction, therapy losing sensitivity to both ACTH and theophylline, whereas patients with insufficient or ineffective ACTH stimulation may have receptor failure before the loss of intracellular function. Thus, responsiveness to iv theophylline may serve not only as a probe of potential adrenocortical reserve, but also as an indicator of pathogenesis.