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The combined pituitary test is used to determine an absence of the normal rises in gonadotrophins, TSH and cortisol after GnRH, TRH and insulin injection.
A basal cortisol measurement must be made before undertaking a combined pituitary test in patients suspected of hypopituitarism. If cortisol is already low, insulin could be dangerous and ACTH should be measured to differentiate between primary and secondary hypocortisolaemia.
Insulin stress test is contraindicated in patients with a history of ischaemic heart disease, ischaemic changes in the ECG or a history of seizures; alternatives testing agents include metyrapone, glucagon or depot synacthen.