Adrenal insufficiency: identification and management

Resource impact summary report

The guideline covers identifying and managing adrenal insufficiency (hypoadrenalism) in babies, children, young people and adults. It aims to improve the treatment of primary, secondary and tertiary adrenal insufficiency, and also the prevention and management of adrenal crisis.

The National Institute of Diabetes and Digestive and Kidney Diseases (NIH) webpage on adrenal insufficiency and Addison’s disease states that in developed countries around 100 to 140 people per million people are impacted by primary adrenal insufficiency (Addison’s disease). This would give a population for England of between 5,700 and 7,900 people.   

Secondary adrenal insufficiency is more common, with prevalence being in the region of 150 to 280 people per million population. Applying these rates to the population of England would give an estimated population of between around 8,500 and 15,800 people. Secondary and tertiary adrenal insufficiency are often grouped together, so no numbers for tertiary adrenal insufficiency by itself are available. 

Most of the recommendations in the adrenal insufficiency guideline reinforce best practice and do not need any additional resources to implement. However, some of the guideline areas and recommendations may represent a change to current local practice. Where a change is required to current practice, this may require additional resources to implement, which may be significant at a local level. Benefits derived from the change in practice may help mitigate any additional costs.

Due to a lack of robust data on current practice and the variation across organisations and services, the size of the resource impact will need to be determined at a local level.

Depending on current local practice, recommendations which may require additional resources and result in additional costs include:

• Emergency management kits (recommendations 1.3.7 to 1.3.11). An emergency management kit contains hydrocortisone for intramuscular injection that can be given by anyone, including the person with adrenal insufficiency, when adrenal crisis is suspected. The cost of the contents of the kit is low and was estimated to be under £2 on average in the evidence review. In addition to the kit contents costs, there will be the cost of staff time associated with training people how to administer emergency hydrocortisone. This is estimated to be £20 per person when training is given on an individual basis and estimated to take 20 minutes of a Band 6 nurse’s time. The committee noted that training could be delivered by a Band 5 to Band 7 nurse and that training could also be provided as group training, particularly for training parents, friends and carers. Group training would reduce the estimated cost. Clinical experts told us that it is standard practice in endocrine centres to issue emergency management kits, however, there may be variation on the contents of these kits, the number of kits issued, and the training given to people with primary and secondary adrenal insufficiency and their family or carers.
• Antenatal care (recommendations 1.4.14 to 1.4.17). Management of hyperemesis gravidarum in an inpatient setting is not routinely happening in current practice. The committee highlighted the importance of inpatient care and noted that although this is more costly than outpatient care, the population for whom this recommendation would apply is small and therefore this should not result in a significant resource impact.
• When and how to test for adrenal insufficiency during glucocorticoid withdrawal (recommendations 1.9.8 and 1.9.9). If this results in a change of practice the resource impact should be assessed locally.

Implementing the guideline may:

• lead to improved consistency of best practice across the country
• lead to improved diagnosis, with the guideline suggesting optimal timings for serum cortisol tests and referral thresholds (recommendations 1.2.4 to 1.2.12). These should also minimise repeat testing and costly and unnecessary referrals to secondary care
• help people to better manage their condition. The guideline provides advice on taking additional glucocorticoids at times of physiological or significant psychological stress (recommendations 1.4.1 to 1.4.9 and 1.5.1 to 1.5.3). The cost of increasing oral corticosteroids for limited periods is small but reduces the risk of the condition deteriorating or them being admitted to hospital
• lead to better health outcomes and care experience.

Endocrine services are commissioned by integrated care boards. Providers are NHS hospital trusts and primary care providers or GPs.