Monitoring of adrenal insufficiency

Once a patient with adrenal insufficiency is stable and well controlled on replacement therapy, an annual review is sufficient.

At each review, measure serum sodium and potassium and plasma renin concentrations. A plasma renin concentration in the upper-normal reference range indicates optimal mineralocorticoid replacement.

Ask the patient about their general wellbeing, and assess for features of:

• glucocorticoid excess—weight gain, facial puffiness, peripheral oedema, insomnia, low bone mineral density (BMD), elevated blood pressure, hyperglycaemia
• glucocorticoid deficiency—weight loss, lack of appetite, progressive skin pigmentation, lethargy
• mineralocorticoid excess—elevated blood pressure, peripheral oedema, hypokalaemia, low plasma renin concentration
• mineralocorticoid deficiency—postural hypotension, tachycardia, hyperkalaemia.

Adjust the dose or timing of replacement therapy if required.

Plasma adrenocorticotrophic hormone (ACTH) concentration does not reliably correlate with the sufficiency of glucocorticoid replacement, so is not useful for assessing the glucocorticoid dose.

Assess BMD every 2 years. A significant decrease in BMD may indicate excess glucocorticoid replacement—review the glucocorticoid dose, and consider the possibility of coeliac disease or thyroid disease. See also Glucocorticoid-induced osteoporosis.

Patients with autoimmune adrenal insufficiency have increased prevalence of other autoimmune disorders (eg coeliac disease, autoimmune thyroid disease, type 1 diabetes, pernicious anaemia). Counsel patients to be aware of the signs and symptoms of these disorders. In addition to clinical monitoring, consider biochemical screening after 1 year, then every 5 years.