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Adrenal Insufficiency

Griffin Bullock


  • Differential: Primary (Adrenals) vs Secondary (Pituitary):
    • Exogenous steroid use (>10 mg for >3wks) undergoing severe physiologic stress or sudden discontinuation of steroid
    • Autoimmune adrenal insufficiency
    • 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


  • Inpatient Setting

    • Draw AM cortisol and ACTH (ideally 8am) -> 0.25mg cosyntropin -> cortisol 1 hour after
      • Cortisol level ≥18-20 rules out primary adrenal insufficiency (and most secondary)
  • Outpatient 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
  • 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

Last update: 2022-06-20 11:22:06