Primary adrenal insufficiency signs and symptoms
The symptoms of adrenal insufficiency are usually subtle and develop gradually, and, except for salt craving are non-specific1
- Many patients with adrenal insufficiency have signs and symptoms of associated diseases – which are seen in as many as 50% of patients2,3
- Unsurprisingly, more than half of people with adrenal insufficiency have symptoms and signs for more than 1 year before diagnosis3
- As a result, the diagnosis is often delayed or missed altogether, with some patients presenting in the emergency department with an acute life-threatening adrenal crisis2
Recent research found that weight loss, fatigue and skin darkening were some of the more commonly seen symptoms of adrenal insufficiency by GPs, but other conditions were suspected because adrenal insufficiency is so rare.4
The wide range of possible symptoms include:5
For more information about symptoms, please click here
Risk factors for adrenal insufficiency include:
OTHER AUTOIMMUNE CONDITIONS
Adrenal insufficiency may occur in isolation but in many cases is associated with other autoimmune conditions. Associated conditions include autoimmune thyroid disease, pernicious anaemia, vitiligo, and type 1 diabetes mellitus6
EXOGENOUS STEROIDS
Patients taking steroids by any route are at risk of adrenal insufficiency (e.g., prednisolone 5 mg/day or equivalent for 4 weeks or longer)7
PATIENTS ON HIGH DOSES OF INHALED STEROIDS
Patients taking inhaled beclomethasone >1000 mcg/day or fluticasone propanoate >500 mcg/day are at risk of adrenal insufficiency due to hypothalamo-pituitary axis suppression7
LONG-TERM OPIOID ANALGESIA
Suppression of the hypothalamic-pituitary-adrenal axis is present in a clinically significant proportion of chronic pain patients treated with opioid analgesia8
Risk factors for adrenal crisis:
All patients with adrenal insufficiency are at risk of an adrenal crisis, particularly during intercurrent illness or an invasive procedure/surgery7
Gastrointestinal illness is the most commonly observed precipitating factor for adrenal crisis in the setting of known or unknown adrenal insufficiency. Other known risk factors include infection, stressful situations, strenuous physical activity, thyrotoxicosis, certain medications, or omission of steroids9
“The symptoms of adrenal insufficiency are usually subtle and develop gradually. It’s hard to tell them apart from signs and symptoms of associated diseases”
Dr Mark Coombe – Senior primary care educator
WHAT IS AN ADRENAL CRISIS?
Patients with adrenal insufficiency should be made constantly aware of the risk of a sudden worsening of symptoms, called an adrenal crisis (sometimes called an Addisonian crisis). This can happen when the levels of cortisol in the body fall significantly.10
Spotting the signs and symptoms of an adrenal crisis11
- Severe weakness
- Syncope (fainting, passing out)
- Hypotension (low blood pressure)
- Confusion
- Abdominal pain, nausea, vomiting
- Abdominal tenderness
- Back pain
- Reduced consciousness, delirium
ADRENAL INSUFFICIENCY OR ADRENAL CRISIS?
To help in identification, the figure below summarises the different signs and symptoms to look for in adrenal insufficiency and those signs and symptoms that occur when a patient is actually experiencing an adrenal crisis.11
The distinction is important as, at least at the outset, signs and symptoms can be similar for both conditions.
Patients may present with some, but not all of the symptoms in the image below.
Click to enlarge
ADRENAL INSUFFICIENCY OR ADRENAL CRISIS?11
To help in identification, the image below summarises the different signs and symptoms to look for in adrenal insufficiency and those signs and symptoms that occur when a patient is actually experiencing an adrenal crisis.
The distinction is important as, at least at the outset, signs and symptoms can be similar for both conditions.
Patients may present with some, but not all of the symptoms in the image below.
Click to enlarge
TREATING ADRENAL INSUFFICIENCY2,3
Patients with primary adrenal insufficiency require steroid replacement for life2,3 and those with secondary adrenal insufficiency and tertiary adrenal insufficiency will require steroids long term, if not for life.2
- All adrenal insufficiency patients on steroids should be encouraged to carry a steroid emergency card and wear a medical alert bracelet or necklace.1,12 This is to inform medical personnel on their steroid dependence status because any delay in the administration of hydrocortisone in an emergency can have serious consequences1,13
- Patients with primary adrenal insufficiency will usually need to have appointments with an endocrinologist frequently so they can review the patient’s progress and, if necessary, adjust their medicine dose. As the primary care physician, you can provide support and repeat prescriptions in between these visits12
Patient profiles
Bill (age 38)
In the military
“I had to wait nearly 2 years for a proper diagnosis.”
Symptoms:
Lack of appetite,
weight loss, fatigue
Risk factors:
Family history of primary adrenal insufficiency
Time to diagnosis:
2 years
Mary (age 47)
Wife and mother
“I had chest pains, but the locum dismissed it as gastric and told me to get a blood test."
Symptoms:
Dizziness, skin darkening, nausea/vomiting
Risk factors:
Type 1 diabetic
Time to diagnosis:
18 months
Sally (age 59)
NHS worker
“I was referred to secondary care, where they confirmed my diagnosis of primary adrenal insufficiency.”
Symptoms:
Weight loss, fatigue, depression
Risk factors:
Suffers from anterior hypopituitarism
Time to diagnosis:
12 months
These patient profiles have been compiled from interviews with patients as part of Market Research carried out on behalf of Pharmanovia. They are not real patients but they are intended to reflect some patient types and patient histories that might be encountered by healthcare professionals.
If you think your patient may have adrenal insufficiency, carry out an early morning cortisol test
References:
- Erichsen MM, et al. J Clin Endocrinol Metab, December 2009; 94(12):4882–4890.
- Kumar R, Wassif WS. J Clin Pathol 2022;75:435–442.
- NICE. https://cks.nice.org.uk/topics/addisons-disease/diagnosis/suspecting-addisons-disease/ [Last accessed March 2023].
- Pharmanovia. Data on file. AD01 December 2022.
- NHS. Symptoms. Addison’s disease. https://www.nhs.uk/conditions/addisons-disease/symptoms/ [Last accessed March 2023].
- NICE. Addison’s disease. https://cks.nice.org.uk/topics/addisons-disease/background-information/associated-conditions [Last accessed March 2023].
- Simpson H, et al. RCP Journals. 2020 https://www.rcpjournals.org/content/clinmedicine/20/4/371 [Last accessed March 2023].
- Gibb FW, et al., Clinical Endocrinology. 2016.85(6): 831-835. https://onlinelibrary.wiley.com/doi/epdf/10.1111/cen.13125 [Last accessed March 2023].
- Elshimy G, et al. https://www.ncbi.nlm.nih.gov/books/NBK499968/ [Last accessed March 2023].
- NHS. Overview. Addison’s disease. https://www.nhs.uk/conditions/addisons-disease/ [Last accessed March 2023].
- Bornstein SR, et al. J Clin Endocrinol Metab 2016;101(2): 364–389.
- NHS. Treatment. Addison’s disease. https://www.nhs.uk/conditions/addisons-disease/treatment/ [Last accessed March 2023].
- NHS. RCGP. https://www.england.nhs.uk/wp-content/uploads/2020/08/NPSA-Emergency-Steroid-Card-FINAL-2.3.pdf [Last accessed March 2023].
References:
- Erichsen MM, et al. J Clin Endocrinol Metab, December 2009; 94(12):4882–4890.
- Kumar R, Wassif WS. J Clin Pathol 2022;75:435–442.
- NICE. https://cks.nice.org.uk/topics/addisons-disease/diagnosis/suspecting-addisons-disease/ [Last accessed December 2022].
- Pharmanovia. Data on file.
- NHS. Symptoms. Addison’s disease. https://www.nhs.uk/conditions/addisons-disease/symptoms/ [Last accessed December 2022].
- Simpson H, et al. RCP Journals. Clin Med (Lond). 2020 Jul;20(4):371-378. https://www.rcpjournals.org/content/clinmedicine/20/4/371fbclid=IwAR09XbjSzKBOtp
YyHjJTWDKPkAkW4tLfe62NvVGjDBL6XMvJe0u50fgHW8 [Last accessed December 2022]. - Meyer G, et al. Clin Endocrinol. (Oxf.). 2016 Sep;85(3):347-53.
- The Endocrinologist.
https://www.endocrinology.org/endocrinologist/122-winter-16/hot-topics/adrenal-insufficiency-with-opioid-analgesia/ [Last accessed December 2022]. - NCBI.
https://www.ncbi.nlm.nih.gov/books/NBK499968/ [Last accessed December 2022]. - NHS. Overview. Addison’s disease.
https://www.nhs.uk/conditions/addisons-disease/ [Last accessed December 2022]. - Bornstein SR, et al. J Clin Endocrinol Metab 2016;101(2): 364–389.
- Pharmanovia. Data on file.
- NHS. Treatment. Addison’s disease.
https://www.nhs.uk/conditions/addisons-disease/treatment/ [Last accessed December 2022]. - NHS. RCGP.
https://www.england.nhs.uk/wp-content/uploads/2020/08/NPSA-Emergency-Steroid-Card-FINAL-2.3.pdf [Last accessed December 2022].