Do you refer patients with suspected adrenal gland problems, particularly those with signs of hormonal imbalances, chronic illness, or symptoms suggestive of adrenal insufficiency (e.g. fatigue, weight loss, hypotension), to endocrinology for further evaluation and management?

Endocrinology Referral for Adrenal Gland Problems

Yes, you should refer patients with suspected adrenal gland problems to endocrinology for all grades of severity, as this is explicitly recommended by ASCO guidelines for comprehensive management, patient education on stress dosing, and long-term monitoring. 1

When Endocrine Referral is Mandatory

All patients with confirmed or suspected adrenal insufficiency require endocrinology consultation regardless of symptom severity. 1 The guidelines are unequivocal on this point:

• Grade 1 (mild/asymptomatic): Endocrine consultation is recommended for initiation of replacement therapy and patient education 1
• Grade 2 (moderate symptoms): Endocrine consultation is required to assess need for stress dosing and guide outpatient management 1
• Grade 3-4 (severe/life-threatening): Immediate endocrine consultation is mandatory, even in emergency settings 1

Specific Clinical Scenarios Requiring Endocrine Referral

Primary Adrenal Insufficiency

• All confirmed cases require endocrinology referral for both glucocorticoid and mineralocorticoid replacement optimization 1
• Patients need specialized education on stress dosing, emergency injectable hydrocortisone use, and medical alert identification 1
• Fludrocortisone dosing (0.05-0.1 mg daily) requires endocrine expertise to titrate based on renin, sodium levels, and volume status 1

Secondary Adrenal Insufficiency (Hypophysitis)

• All grades require referral to endocrinology for evaluation of multiple potential pituitary hormone deficiencies 1
• MRI brain with pituitary cuts should be obtained, particularly with multiple endocrine abnormalities, severe headaches, or vision changes 1
• Corticosteroid replacement must be initiated before other hormone replacements to avoid precipitating adrenal crisis 1

Pre-Operative and High-Stress Situations

• Endocrine consultation should be part of planning before surgery or high-stress treatments such as cytotoxic chemotherapy 1
• This applies at any time during a patient's care, not just at initial diagnosis 1

Persistent or Complex Thyroid Problems

• Persistent thyrotoxicosis beyond 6 weeks requires endocrinology referral for additional workup and possible medical thyroid suppression 1
• Physical examination findings of ophthalmopathy or thyroid bruit are diagnostic of Graves' disease and should prompt early endocrine referral 1

Critical Patient Education Components Requiring Endocrine Expertise

All patients with adrenal insufficiency need comprehensive education that endocrinologists are specifically trained to provide: 1

• Stress dosing protocols for sick days (doubling or tripling maintenance doses during illness, fever, or physical stress) 2
• When to seek immediate medical attention for impending adrenal crisis 1
• Use of emergency injectable hydrocortisone 100 mg IM with self-injection training 2, 3
• Medical alert bracelet or necklace to trigger stress-dose corticosteroids by emergency personnel 1

Diagnostic Workup That May Prompt Referral

Indeterminate Morning Cortisol Results

• Morning cortisol between 3-15 µg/dL (or 250-400 nmol/L) requires ACTH stimulation testing, which often prompts endocrine consultation 1, 2
• The cosyntropin stimulation test (0.25 mg IV/IM with cortisol at 30 and 60 minutes) is the gold standard, with peak cortisol <500 nmol/L (<18 µg/dL) confirming adrenal insufficiency 1, 4

Distinguishing Primary from Secondary Adrenal Insufficiency

• Primary AI: High ACTH with low cortisol, often with hyponatremia and hyperkalemia (though hyperkalemia only present in ~50% of cases) 1, 2
• Secondary AI: Low or inappropriately normal ACTH with low cortisol 2, 4, 3
• This distinction requires endocrine expertise as treatment differs (primary requires both glucocorticoid and mineralocorticoid replacement) 1

Common Pitfalls to Avoid

Never Delay Treatment for Referral

• In suspected adrenal crisis, treatment should NEVER be delayed for diagnostic procedures or specialist consultation 1, 2
• Immediately administer IV hydrocortisone 100 mg (or dexamethasone 4 mg if diagnosis uncertain) plus 0.9% saline infusion at 1 L/hour 1, 2
• Obtain blood for cortisol and ACTH before treatment if possible, but do not delay therapy 2

Don't Rely on Electrolytes Alone

• Absence of hyperkalemia cannot rule out adrenal insufficiency—it's only present in about 50% of cases 2
• Hyponatremia is present in 90% of newly diagnosed cases and can be indistinguishable from SIADH without specific adrenal function testing 2

Avoid Testing While on Corticosteroids

• Morning cortisol measurements in patients actively taking corticosteroids are not diagnostic due to assay cross-reactivity 2
• Laboratory confirmation should not be attempted until corticosteroid treatment is discontinued with sufficient washout time 2
• Hydrocortisone must be held for 24 hours before testing; other steroids require longer washout periods 2

Practical Algorithm for Referral Decision

Refer to endocrinology if ANY of the following are present:

1. Confirmed biochemical adrenal insufficiency (morning cortisol <5 µg/dL with high ACTH, or indeterminate cortisol requiring stimulation testing) 1, 2, 3
2. Clinical suspicion with classic symptoms: fatigue (50-95% of cases), nausea/vomiting (20-62%), weight loss (43-73%), hypotension, or salt craving 3, 5
3. Patients on chronic glucocorticoids (≥20 mg/day prednisone equivalent for ≥3 weeks) who develop unexplained hypotension or are being weaned off steroids 2
4. Pre-operative planning for any patient with known or suspected adrenal insufficiency 1
5. Pituitary lesions or multiple endocrine abnormalities suggesting hypophysitis 1
6. Persistent thyroid dysfunction beyond 6 weeks or suspected Graves' disease 1

The threshold for endocrine referral should be low—these are complex, potentially life-threatening conditions requiring specialized long-term management and patient education that extends far beyond initial diagnosis and treatment initiation. 1