Adrenal Insufficiency Diagnosis and Management

Clinical Presentation and Diagnosis

The initial diagnostic workup for suspected adrenal insufficiency should include paired measurement of morning serum cortisol and plasma ACTH, along with basic metabolic panel to assess electrolytes, as recommended by the American College of Internal Medicine 1, 2
Consider adrenal insufficiency in patients presenting with unexplained collapse, hypotension, vomiting, diarrhea, hyperpigmentation, hyponatremia, hyperkalemia, acidosis, or hypoglycemia, according to the American College of Internal Medicine 1, 3
Treatment of suspected acute adrenal insufficiency should never be delayed by diagnostic procedures, as stated by the American College of Internal Medicine 1

Morning (8 AM) serum cortisol and plasma ACTH should be measured, as recommended by the American College of Internal Medicine 1, 2
Basic metabolic panel (sodium, potassium, CO2, glucose) should be assessed, according to the American Society of Clinical Oncology 4
In acute illness, cortisol <250 nmol/L (9 μg/dL) with elevated ACTH is diagnostic of primary adrenal insufficiency, as stated by the American College of Internal Medicine 1
Cortisol <400 nmol/L (14.5 μg/dL) with elevated ACTH in acute illness raises strong suspicion of primary adrenal insufficiency, according to the American College of Internal Medicine 1

Measure 21-hydroxylase (anti-adrenal) autoantibodies to determine the cause of primary adrenal insufficiency, as recommended by the American College of Internal Medicine 1, 3
If antibodies are negative, obtain adrenal CT imaging to evaluate for hemorrhage, tumor, or infection, according to the American College of Internal Medicine 1, 3
In male patients, measure very long-chain fatty acids to check for adrenoleukodystrophy, as stated by the American College of Internal Medicine 1, 5

Administer IV or IM hydrocortisone 100 mg immediately, followed by 100 mg every 6-8 hours until recovered, as recommended by the American College of Internal Medicine 1
Provide isotonic (0.9%) sodium chloride solution at an initial rate of 1 L/hour until hemodynamic improvement, according to the American College of Internal Medicine 1
Identify and treat the underlying precipitant of adrenal crisis (e.g., infection), as stated by the American College of Internal Medicine 1

Delaying treatment in suspected acute adrenal insufficiency while waiting for test results, as warned by the American College of Internal Medicine 1