What are the symptoms of adrenal insufficiency?

Symptoms of Adrenal Insufficiency

The most common symptoms of adrenal insufficiency include fatigue (50-95%), nausea and vomiting (20-62%), anorexia and weight loss (43-73%), hypotension, salt craving, and hyperpigmentation (in primary adrenal insufficiency). 1

Primary vs. Secondary Adrenal Insufficiency Symptoms

Primary Adrenal Insufficiency (Addison's Disease)

• Fatigue and weakness
• Unintentional weight loss
• Anorexia (loss of appetite)
• Hypotension, especially postural
• Hyperpigmentation of skin (hallmark feature)
• Salt craving
• Abdominal pain
• Muscle pain
• Hyponatremia (low sodium)
• Hyperkalemia (high potassium) 2, 1, 3

Secondary Adrenal Insufficiency

• Similar symptoms as primary but typically:
  • No hyperpigmentation
  • No salt craving
  • Normal electrolytes (no hyperkalemia)
  • Less severe symptoms overall 2, 1

Clinical Assessment for Adrenal Insufficiency

The Endocrine Society recommends assessing for the following symptoms:

Under-replacement symptoms:

• Fatigue
• Nausea
• Poor appetite
• Weight loss
• Increased pigmentation (in primary adrenal insufficiency) 2

Over-replacement symptoms:

• Weight gain
• Insomnia
• Peripheral edema 2, 4

Adrenal Crisis Symptoms

Adrenal crisis is a life-threatening emergency that may present with:

• Severe hypotension
• Shock
• Altered mental status
• Severe abdominal pain
• Vomiting
• Hyponatremia
• Hypoglycemia
• Fever 2, 1, 5

Diagnostic Considerations

Early diagnosis is crucial but often delayed due to the non-specific nature of symptoms. Laboratory findings typically show:

Primary Adrenal Insufficiency:

• Low morning cortisol (<5 μg/dL)
• High ACTH levels
• Low DHEAS levels
• Electrolyte abnormalities (↓Na, ↑K) 2, 1

Secondary Adrenal Insufficiency:

• Low or intermediate morning cortisol (5-10 μg/dL)
• Low or low-normal ACTH levels
• Low DHEAS levels
• Normal electrolytes 2, 1

Common Pitfalls in Diagnosis

• Symptoms are often non-specific and develop gradually over years, leading to delayed diagnosis 6
• Adrenal insufficiency may be overlooked until an adrenal crisis occurs 3, 5
• Physician awareness must be improved to avoid adrenal crisis 3
• Patients with intermediate cortisol levels (5-10 μg/dL) should undergo repeat morning cortisol testing or corticotropin stimulation testing 1

Patient Education and Prevention

All patients with adrenal insufficiency should:

• Learn to recognize early symptoms of adrenal crisis
• Wear medical alert identification
• Carry a steroid alert card
• Have an emergency hydrocortisone injection kit
• Know how to increase medication during illness, medical procedures, or stress 2, 3

Early recognition of symptoms and prompt treatment are essential to prevent adrenal crisis, which occurs in approximately 50% of patients with adrenal insufficiency after diagnosis 3.