Treatment Pathway

Treatment of Adrenal Insufficiency

Adrenal insufficiency occurs when adrenal glands fail to produce sufficient cortisol. Primary (Addison's disease) is from adrenal damage; secondary is from pituitary or hypothalamic dysfunction.

ADA (American Diabetes Association)AACEESE (European Society of Endocrinology)ETA (European Thyroid Association)NICE

Symptoms Causes Treatment When to See a Doctor Related Questions

Adrenal insufficiency occurs when adrenal glands fail to produce sufficient cortisol. Primary (Addison's disease) is from adrenal damage; secondary is from pituitary or hypothalamic dysfunction.

First-Line Treatment Principles

✓Individualise glycaemic targets based on patient age, comorbidities, and hypoglycaemia risk
✓Metformin remains first-line for type 2 diabetes (unless contraindicated)
✓SGLT2 inhibitors and GLP-1 RAs for patients with established CV disease, HF, or CKD
✓Insulin when oral agents insufficient (T2DM) or as primary therapy (T1DM)
✓Thyroid hormone replacement (levothyroxine) is the standard of care for hypothyroidism

Medications Used in Adrenal Insufficiency

PrednisoloneCorticosteroid

Prednisolone is a corticosteroid with potent anti-inflammatory and immunosuppressive effects, used in a wide range of inflammatory and autoimmune conditions.

PrednisoneCorticosteroid

Prednisone is a corticosteroid with potent anti-inflammatory and immunosuppressive effects, used in a wide range of inflammatory and autoimmune conditions.

DexamethasoneCorticosteroid

Dexamethasone is a corticosteroid with potent anti-inflammatory and immunosuppressive effects, used in a wide range of inflammatory and autoimmune conditions.

HydrocortisoneCorticosteroid

Hydrocortisone is a corticosteroid with potent anti-inflammatory and immunosuppressive effects, used in a wide range of inflammatory and autoimmune conditions.

MethylprednisoloneCorticosteroid

Methylprednisolone is a corticosteroid with potent anti-inflammatory and immunosuppressive effects, used in a wide range of inflammatory and autoimmune conditions.

TriamcinoloneCorticosteroid

Triamcinolone is a corticosteroid with potent anti-inflammatory and immunosuppressive effects, used in a wide range of inflammatory and autoimmune conditions.

BetamethasoneCorticosteroid

Betamethasone is a corticosteroid with potent anti-inflammatory and immunosuppressive effects, used in a wide range of inflammatory and autoimmune conditions.

FludrocortisoneCorticosteroid

Fludrocortisone is a corticosteroid with potent anti-inflammatory and immunosuppressive effects, used in a wide range of inflammatory and autoimmune conditions.

Non-Pharmacological Management

•Medical nutrition therapy: calorie-controlled, low-glycaemic-index diet; carbohydrate counting for insulin users
•Structured physical activity: 150 min/week aerobic + resistance training 2×/week
•Weight loss: 5–10% body weight reduces HbA1c by 0.5–2% and improves insulin sensitivity
•Smoking cessation: accelerates diabetes complications (retinopathy, nephropathy)
•Alcohol restriction: masking of hypoglycaemia; contributes to metabolic dysfunction
•Sleep optimisation: poor sleep worsens insulin resistance and metabolic control
•Self-monitoring of blood glucose (SMBG) or continuous glucose monitoring (CGM)

Treatment Goals

🎯HbA1c target: <7% (53 mmol/mol) in most non-pregnant adults; individualised in elderly

🎯Prevention of microvascular complications: retinopathy, nephropathy, neuropathy

🎯CV risk reduction: BP, lipid, and glucose targets

🎯Weight management and metabolic improvement

🎯Euthyroid state in thyroid disorders (TSH in normal range)

Monitoring Parameters

◆HbA1c: every 3 months until stable, then every 6 months (target <7% in most T2DM)
◆Fasting glucose and CGM metrics (time in range >70% for most)
◆Blood pressure: target <130/80 mmHg in diabetes
◆Lipid panel: annually; intensify if LDL >2.5 mmol/L or established ASCVD
◆Renal function (eGFR, urine albumin-creatinine ratio): annually
◆Eye examination (retinal screening): annually
◆Foot examination: at every visit; annual podiatry review
◆TSH monitoring: 6-weekly after levothyroxine initiation, then annually when stable

Escalation Criteria

→HbA1c persistently >10% despite maximal oral therapy → insulin initiation
→Diabetic ketoacidosis (DKA) or hyperosmolar hyperglycaemic state (HHS): emergency hospitalisation
→Severe hypoglycaemia (glucose <3 mmol/L with confusion/loss of consciousness): glucagon, IV dextrose
→New or worsening nephropathy (eGFR <30): nephrology review; restriction of nephrotoxic agents
→Thyroid storm or myxoedema coma: intensive care emergency

Special Populations

Elderly: relax HbA1c targets to 7.5–8% to reduce hypoglycaemia risk; avoid SUs and long-acting insulin

Pregnancy: tight glycaemic control (HbA1c <6.5%); insulin preferred; avoid oral hypoglycaemics in T1DM

CKD: metformin contraindicated if eGFR <30; SGLT2i adjust dose; dose-reduce insulin

Frailty: individualise therapy; avoid polypharmacy and hypoglycaemia-prone regimens

Clinical Insights

Differential Diagnosis

Conditions that mimic Adrenal Insufficiency — key distinguishing features & tests

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