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Adrenal insufficiency (AI) due to corticosteroid administration occurs frequently in those on higher prolonged steroid doses; however, an exact threshold other than high clinical suspicion remains unknown.1 Outside of tertiary AI, adrenal failure is rare and for primary adrenal insufficiency (PAI) involves a combination of both glucocorticoid, mineralocorticoid and androgen deficiency, as outlined in this best practice on adrenal failure.2 Both PAI and secondary adrenal insufficiency (SAI) can take some time for diagnosis, as often signs and symptoms are non-specific, with diagnosis involving clinical suspicion and combination of biochemistry testing and perhaps imaging for initial diagnosis.3 4 Unfortunately, in modern clinical practice, many patients are not diagnosed until the present with an acute adrenal crisis and those with a previous crisis appear to be of greater risk of subsequent events.5 6
Cortisol testing is clearly at the centre of the initial diagnosis with a widespread appreciation of its diurnal variation.7 The variability of cortisol results due to assay methodology is underappreciated with standard guidelines quoting single isolated cut-off values without consideration for the particular lab method involved.8–10 There is uncertainty in the lab analysis much like the uncertainty in the clinical assessment, as many patients present with …
Handling editor Tahir S Pillay.
Correction notice This article has been corrected since it was published Online First. The title has been updaed.
Contributors PJT conceived the submission, discussing this before AR developed the concept further and wrote the initial draft. Both authors discussed and contributed to the final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.