What adrenal condition is associated with salt cravings?

Salt Cravings and Adrenal Insufficiency

Salt craving is a characteristic and highly specific symptom of primary adrenal insufficiency (Addison's disease), not secondary adrenal insufficiency. 1

Pathophysiological Mechanism

Salt craving occurs due to mineralocorticoid (aldosterone) deficiency, which causes sodium loss through the kidneys and disrupts electrolyte balance. 1 This deficiency is present in primary adrenal insufficiency where the adrenal glands themselves are destroyed, but is absent in secondary adrenal insufficiency where only ACTH production from the pituitary is impaired—leaving the renin-angiotensin-aldosterone system intact. 2

Clinical Differentiation: Primary vs Secondary

Primary adrenal insufficiency (Addison's disease):

• Salt craving is present due to aldosterone deficiency 1, 3
• Accompanied by hyperpigmentation (from elevated ACTH) 3
• Hyponatremia present in 90% of cases 3
• Hyperkalemia present in approximately 50% of cases 3
• Orthostatic hypotension is common 1, 3

Secondary adrenal insufficiency:

• Salt craving is absent because aldosterone production remains normal 2
• No hyperpigmentation (ACTH is low) 3
• May have hyponatremia without hyperkalemia 2

Diagnostic and Treatment Implications

Using salt craving as a clinical indicator:

• The presence of salt craving should prompt immediate evaluation for primary adrenal insufficiency 1
• Salt craving can be used to monitor adequacy of mineralocorticoid replacement therapy 4, 1
• Persistent salt craving despite adequate sodium intake indicates the need for increased fludrocortisone dosing 1

Treatment considerations:

• Patients with primary adrenal insufficiency require both glucocorticoid and mineralocorticoid replacement 1
• The typical fludrocortisone dose is 50-200 μg daily, with some patients requiring up to 500 μg daily 2
• Unrestricted sodium salt intake and salty foods are essential components of therapy 1
• Patients should avoid potassium-containing salts marketed as "healthy" 1

Critical Clinical Pearls

Common pitfall: Do not rely solely on electrolyte abnormalities to diagnose primary adrenal insufficiency—hyperkalemia is present in only about 50% of cases at diagnosis, and hyponatremia may be only marginally reduced. 2, 3

Monitoring adequacy of replacement: Assess for salt cravings, measure blood pressure in supine and standing positions, check for peripheral edema, and measure plasma renin activity. 4, 1

Drug interactions to avoid: Liquorice and grapefruit juice potentiate the mineralocorticoid effect of hydrocortisone and should be avoided. 4, 1