From the Guidelines
Chronic adrenal insufficiency typically presents with symptoms such as profound fatigue, muscle weakness, weight loss, and gastrointestinal disturbances, and diagnosis should be considered in patients with unexplained collapse, hypotension, vomiting, or diarrhea, as stated in the consensus statement on the diagnosis, treatment, and follow-up of patients with primary adrenal insufficiency 1.
Common Signs and Symptoms
- Profound fatigue
- Muscle weakness
- Weight loss
- Decreased appetite
- Salt cravings
- Gastrointestinal disturbances such as nausea, vomiting, abdominal pain, and diarrhea
- Hyperpigmentation, particularly in skin creases, scars, and mucous membranes, due to elevated ACTH levels
- Orthostatic hypotension, causing dizziness when standing up
- Mood changes including irritability, depression, and difficulty concentrating
- Loss of body hair and decreased libido in women
Laboratory Findings
- Low serum cortisol
- Low sodium
- High potassium
- Sometimes mild hypoglycemia
Diagnosis and Treatment
The diagnosis of primary adrenal insufficiency should be considered in all patients presenting with unexplained collapse, hypotension, vomiting, or diarrhea, and hyperpigmentation, hyponatraemia, hyperkalaemia, acidosis, and hypoglycaemia increase clinical suspicion of primary adrenal insufficiency 1. Treatment requires lifelong hormone replacement with glucocorticoids, such as hydrocortisone 15-25 mg daily in divided doses, and sometimes mineralocorticoids, such as fludrocortisone 50-200 µg daily 1. All patients with adrenal insufficiency should wear Medic Alert identification jewelry and carry a steroid/alert card, and receive sufficient education to manage daily medications and situations of minor to moderate concurrent illnesses 1.
From the Research
Signs and Symptoms of Chronic Adrenal Insufficiency
The signs and symptoms of chronic adrenal insufficiency can be non-specific and varied, making diagnosis challenging. Some common symptoms include:
- Fatigue and muscle weakness 2
- Weight loss 2, 3
- Low blood pressure 2
- Darkening of the skin (melanoderma) 2, 3
- Abdominal pain 3
- Salt craving 3
- Hyponatremia (low sodium levels) and hyperkalemia (high potassium levels) 3
- Nonspecific symptoms such as loss of appetite, nausea, and vomiting may also be present
Diagnosis and Treatment
Diagnosis of adrenal insufficiency is established by low morning serum cortisol and aldosterone levels, elevated ACTH and renin concentrations, and a standard dose Cosyntropin stimulation test may be needed to confirm the diagnosis 3. Treatment involves glucocorticoid and mineralocorticoid substitution, patient education on dose adjustments during stress, and prevention of acute adrenal crisis 3.
Glucocorticoid-Induced Adrenal Insufficiency
Glucocorticoid-induced adrenal insufficiency is a common form of adrenal insufficiency, caused by exogenous glucocorticoid suppression of the hypothalamic-pituitary-adrenal axis 4, 5. Symptoms of glucocorticoid withdrawal can overlap with those of adrenal insufficiency, making diagnosis challenging 5. A careful approach to glucocorticoid taper and patient counseling are necessary to assure a successful taper 5.
Morbidity and Mortality
Despite conventional glucocorticoid replacement therapy, morbidity remains high, and life expectancy is reduced in patients with adrenal insufficiency 6. The increased morbidity and decreased life expectancy are thought to be due to both increased exposure to cortisol and insufficient cortisol coverage during infections and other stress-related events 6.