What is the workup for adrenal insufficiency (Adrenal Fatigue)?

From the Guidelines

Adrenal fatigue is not a recognized medical diagnosis, so a conventional medical workup should focus on ruling out legitimate adrenal conditions like Addison's disease or adrenal insufficiency. For a proper evaluation, I recommend consulting with an endocrinologist who can order appropriate tests including morning cortisol levels, ACTH stimulation test, and comprehensive metabolic panel, as suggested by the most recent guidelines 1. These tests measure actual adrenal function rather than the vague symptoms associated with "adrenal fatigue." If you're experiencing fatigue, sleep disturbances, body aches, or low energy, these symptoms warrant medical attention but may be related to other conditions like depression, sleep disorders, thyroid dysfunction, or chronic fatigue syndrome. The workup and evaluation should include pulse oximetry, CT chest, and infectious workup if necessary, as outlined in the guidelines 1. While some complementary medicine practitioners may recommend supplements like ashwagandha, rhodiola, or vitamin B complex for what they term adrenal fatigue, these interventions lack strong scientific evidence, and instead, focus on evidence-based approaches to improve energy levels:

• maintain regular sleep patterns (7-9 hours nightly)
• engage in moderate exercise
• practice stress management techniques
• eat a balanced diet
• stay hydrated, as recommended by the guidelines 1. These lifestyle modifications address many of the symptoms attributed to adrenal fatigue and support overall health regardless of the underlying cause of fatigue. It's essential to distinguish primary from secondary hormonal problems to ensure appropriate treatment, and recognizing that a patient has central hypothyroidism can prompt evaluation for secondary adrenal insufficiency, as discussed in the guidelines 1. A comprehensive workup, including morning cortisol levels, ACTH stimulation test, and comprehensive metabolic panel, is crucial for diagnosing and managing adrenal insufficiency, and patients should be referred to an endocrinologist for proper evaluation and treatment 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Diagnosis of Adrenal Insufficiency

The diagnosis of adrenal insufficiency is made by demonstrating low basal and/or stimulated serum cortisol and should be followed by appropriate investigations to establish the underlying aetiology 2. A low baseline cortisol (often <100 nmol/L) alongside raised adrenocorticotropic hormone (ACTH) can be enough to diagnose primary adrenal insufficiency 3. Confirmatory testing can be done using the cosyntropin (Synacthen®) stimulation test or the insulin tolerance test, which is the gold standard for secondary adrenal insufficiency 3.

Key Features of Adrenal Insufficiency

Key features of adrenal insufficiency include:

• Unintentional weight loss
• Anorexia
• Postural hypotension
• Profound fatigue
• Muscle and abdominal pain
• Hyponatraemia
• Skin hyperpigmentation (in primary adrenal insufficiency)
• Salt cravings (in primary adrenal insufficiency) 4

Management of Adrenal Insufficiency

Management of adrenal insufficiency involves:

• Maintenance glucocorticoid replacement, usually given as a twice or thrice daily hydrocortisone preparation 2
• Mineralocorticoid replacement for patients with primary adrenal insufficiency 2
• Regular monitoring for features of under- and over-replacement 2
• Patient education on managing adrenal insufficiency, including advice on how to increase medication during intercurrent illness, medical or dental procedures, and profound stress 4
• Provision of a steroid card, parenteral hydrocortisone, and training for parenteral hydrocortisone administration 4

Adrenal Crisis

Adrenal crisis is a life-threatening medical emergency that must be treated immediately with fluids and corticosteroids 3, 5. The mainstay of treatment in adrenal crisis is hydrocortisone, intravenous fluid, glucose repletion, and treatment of the underlying acute trigger 5. Patients with known adrenal insufficiency are at risk for adrenal crisis, which may occur due to a variety of triggers 5.

Investigation and Evaluation

Investigation and evaluation of adrenal insufficiency include:

• Assessment for the underlying etiology or concomitant condition
• Laboratory analysis
• Imaging, when clinically indicated 5
• Specific testing such as the cosyntropin stimulation test, although not necessary for evaluation in the emergency department setting 5