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Primary adrenal insufficiency and adrenal crisis

Endocrine Society diagnosis, replacement, sick-day preparation and emergency treatment for primary adrenal insufficiency.

JurisdictionUnited States
Source check2026-08-20
Clinical reviewiatroX editorial team 路 Clinical editorial review 路 reviewed 2026-08-20 路 due 2027-08-20
AudienceUnited States healthcare professionals
This is an iatroX educational summary of named United States sources, not an official guideline. It does not replace the complete source documents, local policy, specialist advice or clinical judgement. Use the named authority, current FDA labeling, applicable state law, payer rules and local protocol where relevant.

Scope of this summary

Adults with suspected or confirmed primary adrenal insufficiency, including prevention and recognition of adrenal crisis. Glucocorticoid-induced and pituitary central adrenal insufficiency have separate 2024 and hypopituitarism guidance; congenital adrenal hyperplasia, pregnancy and pediatric dosing require specialist pathways.
sources for this section:Endocrine Society PAI

The Bottom Line

  • Test promptly when unexplained volume depletion, hypotension, hyponatremia, hyperkalemia, fever, abdominal symptoms, hyperpigmentation or hypoglycemia raises suspicion, especially with autoimmune or infectious risk.
  • Use a corticotropin stimulation test to confirm primary adrenal insufficiency when the patient is stable enough; obtain paired ACTH and assess renin and aldosterone to establish primary disease and mineralocorticoid need.
  • If adrenal crisis is suspected, draw cortisol and ACTH if this causes no delay, then give parenteral hydrocortisone and appropriate fluid resuscitation immediately without waiting for results.
  • Provide physiologic glucocorticoid replacement and mineralocorticoid replacement when aldosterone deficiency is confirmed, adjusting clinically rather than trying to normalize ACTH by over-replacement.
  • Teach written sick-day dose escalation, emergency injection, medical identification and supply planning to the patient and a close contact, and rehearse rather than merely document the plan.
sources for this section:Endocrine Society PAI

Practical clinical workflow

1
Review steroid exposure, autoimmune disease, infection, hemorrhage, cancer, pituitary symptoms and medicines; measure electrolytes, glucose and hemodynamics and stabilize any acute illness.
2
In a stable patient, obtain morning cortisol and ACTH and perform the source-recommended stimulation test; investigate autoimmune and other causes after biochemical confirmation.
3
Agree on glucocorticoid timing and mineralocorticoid dose, monitor symptoms, weight, postural blood pressure, edema, electrolytes and renin, and screen for associated autoimmune disease.
4
Issue an emergency kit and written instructions for fever, vomiting, procedure, trauma and travel; verify that replacement and injection supplies are in date and obtainable.
5
Review after any crisis or emergency dose to identify the trigger, adequacy of education, access barriers and whether the diagnosis or maintenance regimen needs reassessment.
sources for this section:Endocrine Society PAI

Safety boundaries and escalation

  • Hypotension, persistent vomiting, severe weakness, confusion, fever, hypoglycemia or collapse in an at-risk patient is an adrenal-crisis emergency; treat before confirmatory testing.
  • A patient unable to retain oral replacement needs parenteral glucocorticoid and urgent assessment rather than repeated oral dosing at home.
  • Excess chronic glucocorticoid causes metabolic, cardiovascular, bone and infection harm; insufficient replacement risks crisis, so adjust from clinical features with endocrine input.
  • Do not abruptly stop chronic supraphysiologic glucocorticoids; the 2024 glucocorticoid-induced-adrenal-insufficiency guideline governs taper and recovery testing.
sources for this section:Endocrine Society PAI

Localization

Use available US hydrocortisone products, emergency-services instructions and medical-alert systems, with payer and pharmacy planning for injectable supply.
sources for this section:Endocrine Society PAI

Source documents

Use the linked source documents for complete recommendations, evidence grading, exclusions and implementation detail.

  1. Endocrine SocietyDiagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guidelinepublished 2016-02-19 路 accessed 2026-08-20
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