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Adrenal Insufficiency

Griffin Bullock


  • Differential: Primary (Adrenals) vs Secondary (Pituitary):
    • Exogenous steroid use (>10mg for >3wks) undergoing severe physiologic stress or sudden discontinuation of steroid
    • Autoimmune adrenal insufficiency (Addison’s)
    • Infection/Infiltration: tuberculosis, sarcoidosis, malignancy
    • Hemorrhage (Waterhouse-Friderichsen syndrome)
    • Pituitary mass/tumor, infarct, infiltration, surgery
    • Trauma


  • Generalized weakness, lightheaded, abdominal pain, nausea, weight loss, fatigue
  • Lab Abnormalities: hyponatremia, hyperkalemia, hypoglycemia


  • Inpt Setting
    • Draw AM cortisol and ACTH (ideally 8am)  0.25mg cosyntropin  cortisol 1h after
      • Cortisol level ≥18-20 rules out primary adrenal insufficiency (and most secondary)
  • Outpt Setting
    • Draw AM cortisol level for screening (>15 rules typically rules out adrenal insufficiency)
    • ACTH stimulation for confirmation


  • Consult endocrine if ACTH stimulation test is abnormal
  • Outpt: physiologic replacement doses usually with hydrocortisone (dosed 8am and ~2-4pm to mimic physiology). Can be dosed based on BSA or estimation based on weight. Ranges from ~20-40mg total daily (ex. 15mg AM, 10mg PM). Pt to increase if acute illness.
  • Adrenal crisis (if concerned, treat first, test later)
    • BMP, glucose monitoring, ACTH level, serum cortisol
    • Fluid resuscitation: NS or D5NS. Do not use hypotonic saline.
    • Hydrocortisone 100mg x1 followed by 50mg q8h