What are the recommended referral criteria for patients with suspected adrenal insufficiency?

Recommended referral criteria for patients with suspected adrenal insufficiency:

• Refer urgently to endocrinology if an 8 am to 9 am serum cortisol level is below 150 nmol/L in people aged 16 years and over, as this indicates probable adrenal insufficiency. Consider starting management for adrenal insufficiency immediately, especially if the person is acutely unwell, following emergency management protocols for adrenal crisis.
• For children and young people aged 1 year to under 16 years, refer urgently to paediatrics or paediatric endocrinology if serum cortisol is below 150 nmol/L, with urgent referral if acutely unwell.
• If serum cortisol levels are between 150 nmol/L and 300 nmol/L, the probability of adrenal insufficiency is uncertain; consider repeating the test and seek endocrinology advice or referral if levels remain in this range.
• For babies under 1 year, measure serum cortisol at any time and seek paediatric endocrinology advice for interpretation and referral decisions.
• Consider adrenal insufficiency in people with unexplained symptoms such as hyperpigmentation, weight loss, salt craving, nausea, vomiting, hypotension, hyponatraemia, hyperkalaemia, hypoglycaemia (especially in children), and other listed features, particularly if they have risk factors like recent glucocorticoid use, pituitary disease, or autoimmune conditions.
• Do not test or refer for adrenal insufficiency in people currently taking oral glucocorticoids at physiological equivalent doses or above, as testing is unreliable in this context.

Referral should be made promptly to specialist endocrinology or paediatric endocrinology services based on these criteria to ensure timely diagnosis and management.

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