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Thoughts on adrenal insufficiency best practice article
  1. Aidan Ryan1,
  2. Patrick J Twomey2,3
  1. 1National Centre for Inherited Metabolic Disorders Adult Service, The Mater Misericordiae University Hospital, Dublin, Ireland
  2. 2Clinical Chemistry, St Vincent's University Hospital, Dublin, Ireland
  3. 3School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
  1. Correspondence to Dr Patrick J Twomey, Clinical Chemistry, St Vincent's University Hospital, Dublin, Ireland; pattwomey{at}doctors.net.uk

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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 …

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Footnotes

  • Handling editor Tahir S Pillay.

  • 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.

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