Primary and secondary adrenal insufficiency — Rapid

Synopsis

Recognise cortisol deficiency early, distinguish adrenal from pituitary or glucocorticoid-induced disease, investigate safely and establish replacement that prevents avoidable adrenal crisis.

Primary adrenal insufficiency is failure of the adrenal cortex: cortisol and often aldosterone are deficient, ACTH rises, and hyperpigmentation, salt craving, postural hypotension, hyponatraemia and hyperkalaemia may occur.
Secondary or tertiary insufficiency reflects pituitary/hypothalamic disease or suppression by exogenous glucocorticoids. ACTH is low or inappropriately normal, aldosterone is usually preserved and hyperkalaemia is not a typical isolated feature.
Symptoms are non-specific: fatigue, weight loss, anorexia, nausea, abdominal discomfort and dizziness. Recurrent unexplained hyponatraemia or deterioration during infection should raise the diagnostic priority.

Key red flags

Evolving adrenal crisis

Worsening vomiting, diarrhoea, abdominal pain, profound weakness, confusion, hypotension, hypoglycaemia or shock demands emergency hydrocortisone and fluids. A normal potassium does not exclude crisis.

Investigation priorities

08:00 to 09:00 serum cortisolFirst step

Screen for impaired morning cortisol production in a stable adult not taking interfering glucocorticoid.

Management branches

Stable suspicionConfirm without creating crisis risk

Chronic compatible symptoms or unexplained hyponatraemia without current haemodynamic instability.

Review all steroid exposures, timing, shift work and comorbidity; arrange an 08:00 to 09:00 cortisol with electrolytes and glucose using the local testing instructions.
If cortisol is low or indeterminate, seek endocrinology advice for paired ACTH and dynamic testing, while giving interim emergency precautions when clinical risk is material.

Key medicines

Hydrocortisone physiological replacementNICE adult total 15 to 25 mg daily by mouth in two to four divided doses, individualised by endocrinology and clinical response.

Prednisolone replacement alternativeNICE lists 3 to 5 mg orally daily in one or two doses for adults when hydrocortisone is unsuitable or adherence favours longer action.

Open full textbook →Answer 2 questions