Diagnosing Adrenal Insufficiency: The 'Quick and Dirty' Method

The Curbsiders share an endocrinologist's tips on recognizing, diagnosing, and treating adrenal insufficiency.
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-- TRANSCRIPT --
Matthew F. Watto, MD: Welcome back to The Curbsiders. I'm Dr Matthew Watto, here with America's primary care physician, Dr Paul Nelson Williams. Paul, are you ready to talk about some adrenal insufficiency? We had a great conversation with Dr Kargi, and I'd like you to start us off.
Paul N. Williams, MD: How about thinking about it? It's a good place to start.
That's one of the ways this episode changed my approach a little bit. I never really thought about the fact that many patients present for evaluation of adrenal insufficiency from gastroenterology clinics. It's such a protean sort of nonspecific presentation. But if you have someone with chronic malaise and poor appetite and maybe unexplained weight loss, and your GI workup is not really leading you anywhere, it's probably worth thinking about adrenal insufficiency. Even though primary adrenal insufficiency is pretty rare - we're talking cases per millions - secondary adrenal insufficiency is actually fairly common. It's probably worth thinking about and testing for more often than I have in the past. So for me, it's having a lower threshold to start looking for it.
Watto: When it's adrenal crisis, you probably think about it, but then it's too late. Ideally, you would think about it before that happens. But the symptoms can be quite vague. The mineralocorticoid symptoms, like salt cravings, dizziness, near syncope, muscle cramps, might make me think of it because they sound more like something endocrine is going on. But if it's just a little weight loss, a little fatigue, or a little nausea, that's everybody.
Williams: Right. If a patient came to me saying, "I'm craving salt," that might hasten the workup a little bit, but that's not the typical presentation.
Watto: If you are going to check a cortisol level, you should really check it in the morning, between 7 AM and 9 AM. If you check it too early, it might not have peaked yet, so you might get a level that looks low. But if you had checked an hour or 2 later, it might have been above a threshold, and then you would know you could rule out the diagnosis.
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