Which medical specialty treats adrenal insufficiency?

Endocrinologists Are the Primary Specialists for Managing Adrenal Insufficiency

Adrenal insufficiency should be managed by an endocrinologist as the primary specialist due to their expertise in hormonal disorders and the complexity of treatment required. 1

Understanding Adrenal Insufficiency

Adrenal insufficiency (AI) is a condition characterized by inadequate production of adrenal hormones, primarily cortisol, with or without deficiency in mineralocorticoids and adrenal androgens. It can be classified as:

• Primary adrenal insufficiency: Direct failure of the adrenal glands (e.g., autoimmune destruction, Addison's disease)
• Secondary adrenal insufficiency: Due to pituitary disorders affecting ACTH production
• Tertiary/Iatrogenic adrenal insufficiency: Most commonly caused by exogenous glucocorticoid therapy

Why Endocrinologists Are the Specialists of Choice

1. Specialized Expertise: Endocrinologists have specific training in diagnosing and managing hormonal disorders, including the complex hypothalamic-pituitary-adrenal axis 1

2. Diagnostic Capabilities: They are trained to interpret specialized testing such as:

   • Morning cortisol and ACTH levels
   • ACTH stimulation tests
   • Adrenal antibody testing
   • Evaluation of mineralocorticoid function

3. Treatment Management: Endocrinologists are experienced in:

   • Individualizing glucocorticoid replacement regimens
   • Managing mineralocorticoid replacement when needed
   • Adjusting treatment during illness, surgery, or stress 1
   • Preventing and managing adrenal crises

4. Guidelines Expertise: Current clinical practice guidelines for adrenal insufficiency are developed primarily by endocrine societies 1

Collaborative Care

While endocrinologists lead the management of adrenal insufficiency, other specialists may be involved:

• Anesthesiologists: For perioperative management of glucocorticoid replacement 1
• Critical care specialists: For management of adrenal crisis
• Oncologists: When adrenal insufficiency is related to cancer treatment or immune checkpoint inhibitors 1
• Primary care physicians: For ongoing monitoring in stable patients

Management Approach

Endocrinologists typically follow this approach for adrenal insufficiency:

1. Diagnosis confirmation:

   • Morning cortisol and ACTH levels
   • ACTH stimulation testing when needed
   • Evaluation for underlying causes

2. Treatment initiation:

   • Hydrocortisone (15-25 mg daily) or prednisone (3-5 mg daily) 2
   • Fludrocortisone (0.05-0.3 mg daily) for primary adrenal insufficiency 2

3. Patient education:

   • Stress dosing protocols
   • Emergency injection training
   • Medical alert identification

4. Ongoing monitoring:

   • Regular assessment of symptoms
   • Adjustment of replacement doses
   • Screening for complications

Special Considerations

• Perioperative management: Requires specific protocols with hydrocortisone 100 mg IV at induction followed by continuous infusion or repeated dosing 1

• Adrenal crisis prevention: All patients need education on stress dosing and emergency hydrocortisone injection 1, 2

• Long-term follow-up: Regular endocrine consultation is essential to adjust treatment and monitor for complications

In conclusion, while management of adrenal insufficiency may involve multiple specialists depending on the clinical scenario, endocrinologists are the primary specialists responsible for diagnosing, treating, and providing ongoing care for patients with this potentially life-threatening condition.