Summary
Definition
History and exam
Key diagnostic factors
- presence of risk factors
- sudden cessation or rapid tapering of glucocorticoids
- acute circulatory collapse with hypotension and tachycardia
Other diagnostic factors
- lassitude and generalised constitutional symptoms
- history of weight gain and increased appetite
- history of depression, agitation, or sleep disorders
- cushingoid examination features
- history of difficult-to-control diabetes or hypertension
- absence of hyperpigmentation or autoimmune stigmata
- medroxyprogesterone use
- history of treatment for endogenous Cushing's syndrome
Risk factors
- systemic glucocorticoid administration
- high potency or dose of exogenous glucocorticoids
- prolonged glucocorticoid treatment (e.g., >3 weeks)
- local glucocorticoid administration
- megestrol use
- intermittent high-dose exogenous glucocorticoid
- non-physiological scheduling of glucocorticoid dose
- medroxyprogesterone use
Diagnostic investigations
1st investigations to order
- serum comprehensive chemistry panel
- serum a.m. cortisol
- adrenocorticotropic hormone (ACTH) stimulation test
- FBC
- thyroid function tests
Investigations to consider
- insulin tolerance test (ITT)
- overnight metyrapone test
- urine synthetic glucocorticoids
Emerging tests
- home waking salivary cortisone
Treatment algorithm
features of adrenal crisis
minor intercurrent stress
severe intercurrent stress
stable patients taking corticosteroids for underlying disease: suitable for discontinuation or taper
Contributors
Authors
Suzanne L. Quinn Martinez, MD

Staff Endocrinologist
HCA Florida Orange Park
Program Director, Internal Medicine
Orange Park
FL
Disclosures
SLQM declares that she has no competing interests.
Acknowledgements
Dr Suzanne L. Quinn Martinez would like to gratefully acknowledge Dr M. Cecilia Lansang, a previous contributor to this topic.
Disclosures
MCL is a consultant for the Sanofi group of companies and is an author of several references cited in this topic.
Peer reviewers
Tiffany M Cortes, MD
Assistant Professor of Medicine
Division of Endocrinology
UT Health Science Center San Antonio
San Antonio
TX
Disclosures
TMC declares that she has no competing interests.
Antoine Tabarin, MD
Head
Department of Endocrinology
University Hospital of Bordeaux
Pessac
France
Disclosures
AT declares that he has no competing interests.
Maralyn Druce, MA, MBBS, MRCP, PhD
Clinical Lecturer
Honorary Consultant
Department of Endocrinology
Barts and The London School of Medicine and Dentistry
St Bartholomew's Hospital
London
UK
Disclosures
MD declares that she has no competing interests.
References
Key articles
Prete A, Bancos I. Glucocorticoid induced adrenal insufficiency. BMJ. 2021 Jul 12;374:n1380.Full text Abstract
Liu D, Ahmet A, Ward L, et al. A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy. Allergy Asthma Clin Immunol. 2013 Aug 15;9(1):30.Full text Abstract
Beuschlein F, Else T, Bancos I, et al. European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: diagnosis and therapy of glucocorticoid-induced adrenal insufficiency. J Clin Endocrinol Metab. 2024 Jun 17;109(7):1657-83.Full text Abstract
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.Full text Abstract
Woodcock T, Barker P, Daniel S, et al. Guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency: guidelines from the Association of Anaesthetists, the Royal College of Physicians and the Society for Endocrinology UK. Anaesthesia. 2020 May;75(5):654-63.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Primary adrenal insufficiency
- Pituitary compression, tumour, head trauma, and surgery (non-Cushing's)
- Corticosteroid withdrawal syndrome
More DifferentialsGuidelines
- European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: diagnosis and therapy of glucocorticoid-induced adrenal insufficiency
- Adrenal insufficiency and adrenal crisis-who is at risk and how should they be managed safely
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