From the Guidelines
For a patient with underlying anxiety requesting adrenal gland laboratory tests, the recommended approach is to first conduct a thorough clinical evaluation before ordering tests, as routine adrenal testing is not indicated in the absence of specific adrenal-related symptoms. Begin with a comprehensive history and physical examination to assess for specific symptoms of adrenal disorders versus anxiety, considering that anxiety disorders can begin in childhood and often decline beginning at approximately age 60 years 1. If the patient's presentation is consistent with anxiety without clinical features suggesting adrenal dysfunction (such as Cushing's syndrome or adrenal insufficiency), explain that routine adrenal testing is not indicated. Instead, focus on addressing the anxiety directly through cognitive behavioral therapy, mindfulness techniques, and possibly medications such as SSRIs (e.g., sertraline 50-100 mg daily or escitalopram 10-20 mg daily) or benzodiazepines for short-term use (e.g., lorazepam 0.5-1 mg as needed). The 2023 guideline update from the Journal of Clinical Oncology recommends screening for anxiety using a valid and reliable tool, such as the GAD-7 scale, to identify patients with generalized anxiety disorder (GAD) 1. If specific adrenal-related symptoms are present, targeted testing may include morning cortisol levels, ACTH stimulation test, or 24-hour urinary free cortisol. This approach balances patient concerns while avoiding unnecessary testing that could lead to false positives, increased anxiety, and medical costs. Educating the patient about how anxiety symptoms can mimic endocrine disorders and providing reassurance about the absence of adrenal disease is often therapeutic in itself. Key points to consider include:
- Screening for anxiety using a valid and reliable tool, such as the GAD-7 scale
- Assessing for specific symptoms of adrenal disorders versus anxiety
- Focusing on addressing anxiety directly through cognitive behavioral therapy, mindfulness techniques, and possibly medications
- Targeted testing for adrenal-related symptoms, if present
- Educating the patient about the relationship between anxiety and endocrine disorders.
From the Research
Approach to Adrenal Gland Laboratory Tests
The patient's request for adrenal gland laboratory tests can be approached by considering the following:
- Evaluating the patient's symptoms and medical history to determine if adrenal insufficiency is a potential cause of their anxiety or other symptoms 2, 3
- Ordering laboratory tests such as baseline cortisol and adrenocorticotropic hormone (ACTH) levels to diagnose primary or secondary adrenal insufficiency 2
- Considering confirmatory testing such as the cosyntropin (Synacthen®) stimulation test or the insulin tolerance test if initial results are inconclusive 2
- Assessing the patient's overall health and potential underlying causes of adrenal insufficiency, such as autoimmune disorders or exogenous glucocorticoid use 3, 4
Diagnostic Considerations
When evaluating the patient's symptoms and laboratory results, consider the following:
- Adrenal insufficiency can present with non-specific symptoms, making diagnosis challenging 3, 5
- The diagnosis of adrenal insufficiency is based on measurement of adrenal corticosteroid hormones, their regulatory peptide hormones, and stimulation tests 5
- The goal of therapy is to establish a hormone replacement regimen that closely mimics the physiological diurnal cortisol secretion pattern, tailored to the patient's daily needs 5
Management and Education
Once a diagnosis is made, consider the following:
- Patient education and empowerment are crucial in managing adrenal insufficiency and preventing adrenal crisis 2, 4
- Providing patients with glucocorticoid emergency cards and injection kits can help prevent life-threatening adrenal emergencies 5
- Regular follow-up and monitoring of the patient's condition are necessary to adjust treatment and prevent complications 4, 5