Adrenal Insufficiency (Addison’s Disease)

Adrenal insufficiency means that the adrenal glands, which sit above the kidneys, do not make enough cortisol. In primary adrenal insufficiency (Addison's disease) the glands themselves are damaged and aldosterone is usually lacking too. In secondary insufficiency the pituitary gland fails to send the signal, or long-term steroid medicines have switched the system off.

It is uncommon, develops slowly and is often missed for months. Once recognised, it is treated with daily hormone replacement for life. The main danger is an adrenal crisis during illness, injury or surgery, which is preventable when you know the sick day rules.

Symptoms

• Persistent fatigue and muscle weakness
• Weight loss and poor appetite
• Nausea, vomiting, abdominal pain
• Dizziness on standing from low blood pressure
• Craving for salt
• Darkening of the skin, palm creases, scars and gums in Addison's disease
• Low mood and poor concentration
• Low blood sugar, particularly in children
• Loss of underarm and pubic hair and reduced libido in women

Causes and risk factors

In developed countries about 8 in 10 cases of Addison's disease are autoimmune, often alongside thyroid disease, type 1 diabetes or vitiligo. Tuberculosis remains an important cause worldwide. Others include bleeding into the glands, fungal infection, HIV, cancer deposits, removal of both adrenals, checkpoint inhibitor cancer drugs and genetic conditions such as congenital adrenal hyperplasia. Secondary causes are pituitary tumours, pituitary surgery or radiotherapy, and above all stopping long-term steroid tablets, injections or high dose inhalers too quickly.

How it is diagnosed

• Morning cortisol and ACTH: A low early morning cortisol with a high ACTH points to primary disease; low or normal ACTH suggests a pituitary cause.
• Short Synacthen test: Cortisol is measured before and 30 to 60 minutes after an injection of synthetic ACTH. A poor rise confirms the diagnosis.
• Electrolytes, renin and aldosterone: Low sodium, high potassium and a high renin show mineralocorticoid deficiency.
• 21-hydroxylase antibodies: Confirm an autoimmune cause.
• Adrenal CT or pituitary MRI: Looks for infection, bleeding or tumour when antibodies are negative, or for a pituitary lesion in secondary disease.

Treatment options

• Hydrocortisone replacement: Usually 15 to 25 milligrams a day split into 2 or 3 doses, the largest on waking. Prednisolone or modified release hydrocortisone are alternatives.
• Fludrocortisone: A once daily tablet replacing aldosterone in primary disease, adjusted by blood pressure, potassium and renin.
• Sick day rules: Double or triple the hydrocortisone dose during fever or significant illness, and use an injection if you are vomiting.
• Emergency hydrocortisone kit: A 100 milligram injection kept at home and when travelling, with a steroid alert card or bracelet.
• Stress dosing for procedures: Extra intravenous hydrocortisone around surgery, labour and endoscopy.
• Treating the cause: Anti-tuberculous therapy, pituitary hormone replacement or a supervised slow steroid taper as appropriate.

When it is urgent

Adrenal crisis is life-threatening. Severe vomiting or diarrhoea, extreme weakness, confusion, collapse, or very low blood pressure in someone with adrenal insufficiency needs an immediate hydrocortisone injection and an emergency ambulance. Do not wait to see whether tablets stay down.

Travelling to Türkiye for treatment

Diagnosis takes only a few tests, so a short visit can confirm or exclude adrenal insufficiency and look for the cause, and an endocrine review is sensible before any planned surgery abroad. Dose adjustment and crisis prevention are lifelong and need an endocrinologist near home. If you already have the condition and are travelling for another procedure, tell the surgical team, carry double supplies of medicine in hand luggage and bring your injection kit with a doctor's letter.

Send your reports, scans and a short history and a Clinic-Y coordinator replies within 24 hours with suitable teams and written, all-inclusive proposals side by side. Reviewing your case is free.

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