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Primary adrenal insufficiency

Last reviewed: 11 Aug 2025
Last updated: 03 May 2022

Summary

Definition

History and exam

Key diagnostic factors

  • presence of risk factors
  • fatigue
  • anorexia
  • weight loss
  • hyperpigmentation
  • acute circulatory collapse with hypotension and tachycardia
  • salt craving
Full details

Other diagnostic factors

  • gastrointestinal symptoms (nausea, vomiting, abdominal pain)
  • postural hypotension
  • arthralgia and myalgia
  • axillary and pubic hair loss in women
Full details

Risk factors

  • female sex
  • adrenocortical autoantibodies
  • adrenal haemorrhage
  • autoimmune diseases
  • coeliac disease
  • tuberculosis (TB)
  • non-TB bacterial infection
  • fungal infection
  • HIV
  • drugs that inhibit cortisol production
  • metastatic malignancy
  • sarcoidosis
Full details

Diagnostic investigations

1st investigations to order

  • morning serum cortisol
  • plasma adrenocorticotrophic hormone (ACTH)
  • serum electrolytes
  • urea and creatinine
  • FBC
Full details

Investigations to consider

  • adrenocorticotrophic hormone (ACTH) stimulation test
  • plasma renin activity
  • serum aldosterone
  • serum dehydroepiandrosterone (DHEA) and DHEA sulfate (DHEA-S)
  • adrenal antibodies
  • adrenal CT or MRI
  • insulin hypoglycaemia test
  • overnight single-dose metyrapone test
Full details

Treatment algorithm

INITIAL

adrenal crisis

ACUTE

minor intercurrent stress

severe intercurrent stress

ONGOING

stable and/or after treatment of acute episode

Contributors

Authors

Laleh Razavi Nematollahi, MD

Assistant Professor of Medicine

Division of Clinical and Molecular Endocrinology and Metabolism

University Hospitals Cleveland Medical Center

Case Western Reserve University

Cleveland

OH

Declarações

LRN declares that she has no competing interests.

Baha Arafah, MD

Chief, Division of Endocrinology

University Hospitals Cleveland Medical Center

Case Western Reserve University

Cleveland

OH

Declarações

BA declares that he has no competing interests.

Agradecimentos

Dr Laleh Razavi Nematollahi and Dr Baha Arafah would like to gratefully acknowledge Dr T. Joseph McKenna, Dr Shehzad Basaria, and Dr Milena Braga-Basaria, previous contributors to this topic.

Declarações

TJM, SB, and MBB declare that they have no competing interests.

Revisores

Rajesh K. Garg, MD

Instructor in Medicine

Brigham and Women's Hospital

Division of Endocrinology

Diabetes and Hypertension

Boston

MA

Declarações

RKG declares that he has no competing interests.

Antoine Tabarin, MD

Head

Department of Endocrinology

Centre Hospitalier Universitaire de Bordeaux

Pessac

France

Declarações

AT declares that he has no competing interests.

Blandine Gatta-Cherifi, MD

Department of Endocrinology

Centre Hospitalier Universitaire de Bordeaux

Pessac

France

Declarações

BGC declares that she has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

Referências

Nossas equipes internas de editoria e de evidências trabalham em conjunto com colaboradores internacionais especializados e pares revisores para garantir que forneçamos acesso às informações o mais clinicamente relevantes possível.

Principais artigos

Bornstein SR, Allolio B, Arlt W, et al. Diagnosis and treatment of primary adrenal insufficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2016 Feb;101(2):364-89.Texto completo  Resumo

Husebye ES, Pearce SH, Krone NP, et al. Adrenal insufficiency. Lancet. 2021 Feb 13;397(10274):613-29. Resumo

Betterle C, Presotto F, Furmaniak J. Epidemiology, pathogenesis, and diagnosis of Addison's disease in adults. J Endocrinol Invest. 2019 Dec;42(12):1407-33. Resumo

Arlt W; Society for Endocrinology Clinical Committee. Society For Endocrinology endocrine emergency guidance: emergency management of acute adrenal insufficiency (adrenal crisis) in adult patients. Endocr Connect. 2016 Sep;5(5):G1-3.Texto completo  Resumo

Artigos de referência

Uma lista completa das fontes referenciadas neste tópico está disponível para os usuários com acesso total ao BMJ Best Practice.
  • Primary adrenal insufficiency images
  • Diagnósticos diferenciais

    • Adrenal suppression due to the use of glucocorticoid or other drugs with glucocorticoid activity (e.g., medroxyprogesterone acetate therapy)
    • Central (secondary or tertiary) adrenal insufficiency (pituitary or hypothalamic lesions)
    • Haemochromatosis
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  • Guidelines

    • Guidelines for the management and prevention of acute adrenal insufficiency
    • Adrenal insufficiency - emergency management practice guideline
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  • Patient information

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    Primary adrenal insufficiency (Addison's disease): what are the treatment options?

    More Patient information
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