Adrenal Insufficiency

Exam Cram

• Adrenal glands produce steroids- glucocorticoids and mineralocorticoids & androgens; therefore in adrenal insufficiency there are low levels of steroids & androgens

• Presentation: generalised weakness, low Na+, high K+, hypotensive, hypoglycaemia

• Diagnosis: low cortisol following ACTH bolus (short synACTHen test)

• Management: hydrocortisone (glucocorticoid) and fludrocortisone (mineralocorticoid)

Outline

Assessment 

History

• Global weakness with infective symptoms

• Loss of consciousness - syncope/ presyncope

• Background: long term steroids or autoimmune conditions

Examination

• Dehydrated

• Hypotension with postural drop

Investigations

• HypoNatraemia , HyperKalaemia (or upper limits of normal)

• HypoGlycaemia 

Diagnosis 

Diagnostic framework:

1. Random cortisol: if > 150 unlikely

2. Morning short synACTHen test

   • If cortisol fails to rise, diagnose adrenal insufficiency

3. ACTH 

   • Low: pituitary issue

   • High: adrenal issue

Differentials: Sepsis , Hypothermia , Hypothyroid coma 

Classification: (aetiology)

1. Primary (adrenal issue)

   • Addison's Disease: autoimmune adrenal destruction

   • Adrenal metastasis (1%), 

   • Adrenal haemorrhage, adrenalectomy

2. Secondary (pituitary issue)

   • Iatrogenic suppression with chronic steroids (e.g. PMR )

   • Pituitary tumours or surgery

   • Sheehan's Syndrome

Management

Acute

Stabilise patient

• Double basal steroids

• If unwell/ unsure of dose- Hydrocortisone 200mg IV stat + 100mg QID (plenty)

Long term

Investigate underlying cause: ACTH & focused imaging. 

Medical Registrar Notes

Debate about the utility of morning/ random cortisol and if high whether it can rule out adrenal insufficiency. 

References and Resources

1. https://thecurbsiders.com/curbsiders-podcast/411-adrenal-insufficiency-with-dr-atil-kargi

2. https://www.endocrine.org/patient-engagement/endocrine-library/adrenal-insufficiency

Written in 2025