Adrenal insufficiency

• Published in: The Lancet (British edition) Vol. 397; no. 10274; pp. 613 - 629
• Main Authors: Husebye, Eystein S, Pearce, Simon H, Krone, Nils P, Kämpe, Olle
• Format: Journal Article
• Language: English
• Published: England Elsevier Ltd 13.02.2021; Elsevier B.V; Elsevier Limited
• Subjects: ACTH; Adrenal glands; Adrenocorticotropic hormone; Age; Alopecia; Anorexia; Autoimmune diseases; Baldness; Celiac disease; Children; Congenital diseases; Diabetes; Diagnosis; Disease; Eating disorders; Glucocorticoids; Health aspects; Hormones; Hydrocortisone; Hyperpigmentation; Hyperplasia; Hyponatremia; Hypotension; Illnesses; Infections; Lymphocytes; Medical research; Medicin och hälsovetenskap; Medicine, Experimental; Metastasis; Mitochondrial DNA; Mortality; Muscles; Muscular fatigue; Mutation; Norway; Opioids; Ovaries; Patient education; Patients; Physicians; Pituitary gland; Quality of life; Seminars; Steroids; Thyroid gland; Tuberculosis; Tumors; Viral infections; Vomiting; Weight loss; Work capacity; Norway; United Kingdom > UK
• ISSN: 0140-6736; 1474-547X; 1474-547X
• DOI: 10.1016/S0140-6736(21)00136-7

Adrenal insufficiency can arise from a primary adrenal disorder, secondary to adrenocorticotropic hormone deficiency, or by suppression of adrenocorticotropic hormone by exogenous glucocorticoid or opioid medications. Hallmark clinical features are unintentional weight loss, anorexia, postural hypotension, profound fatigue, muscle and abdominal pain, and hyponatraemia. Additionally, patients with primary adrenal insufficiency usually develop skin hyperpigmentation and crave salt. Diagnosis of adrenal insufficiency is usually delayed because the initial presentation is often non-specific; physician awareness must be improved to avoid adrenal crisis. Despite state-of-the-art steroid replacement therapy, reduced quality of life and work capacity, and increased mortality is reported in patients with primary or secondary adrenal insufficiency. Active and repeated patient education on managing adrenal insufficiency, including advice on how to increase medication during intercurrent illness, medical or dental procedures, and profound stress, is required to prevent adrenal crisis, which occurs in about 50% of patients with adrenal insufficiency after diagnosis. It is good practice for physicians to provide patients with a steroid card, parenteral hydrocortisone, and training for parenteral hydrocortisone administration, in case of vomiting or severe illness. New modes of glucocorticoid delivery could improve the quality of life in some patients with adrenal insufficiency, and further advances in oral and parenteral therapy will probably emerge in the next few years.