Adrenal insufficiency: identification and management

Context

Adrenal insufficiency is the inadequate production of corticosteroid hormones, glucocorticoids, mineralocorticoids, and androgens by the adrenal glands. Adrenal insufficiency may be primary, secondary or tertiary.

Some medicines cause adrenal insufficiency, such as opioids, checkpoint inhibitors (used increasingly for treating cancer), and medicines inhibiting cortisol clearance such as antifungals and antiretrovirals.

Adrenal insufficiency may have a considerable effect on daily living and may lead to an adrenal crisis if not identified and treated. Common causes of adrenal crisis in people with adrenal insufficiency are gastrointestinal illness (23%), other infections (25%), surgery (10%) and physiological stress (9%). An adrenal crisis is a medical emergency and can be fatal.

The mainstay of adrenal insufficiency management is replacement with glucocorticoids (and mineralocorticoids in primary adrenal insufficiency). These medicines are usually given orally, to maintain a good quality of life and to prevent adrenal crisis. Treatment for adrenal crisis typically includes prompt and appropriate administration of glucocorticoids (hydrocortisone intravenously or intramuscularly) and adequate intravenous fluid hydration with crystalloid.

Care is variable in the UK and small numbers of people die each year from adrenal crisis. Although deaths are rare and avoidable, awareness needs to be raised about the importance of glucocorticoid replacement for people with adrenal insufficiency who are at risk of adrenal crisis. There is an adult NHS Steroid Emergency Card and paediatric British Society of Paediatric Endocrinology and Diabetes (BSPED) Steroid Emergency Card for people at risk to help ensure prompt, appropriate treatment if they have an adrenal crisis.

Better recognition of people at risk of adrenal insufficiency, and awareness of the acute- and long-term management of adrenal insufficiency, would improve patient care and quality of life, and reduce associated complications. This guideline aims to improve the management of adrenal insufficiency and the quality of life of people with adrenal insufficiency.