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Practice Guidelines

Adrenal insufficiency: identification and management—summary of new NICE guidance

BMJ 2025; 389 doi: https://doi.org/10.1136/bmj.r330 (Published 01 May 2025) Cite this as: BMJ 2025;389:r330
  1. Saoussen Ftouh, senior technical analyst1,
  2. Madelaine Zucker, technical analyst1,
  3. Anh Tran, associate salaried GP with special interest in diabetes and endocrinology2,
  4. Sally Tollerfield, paediatric endocrine clinical nurse specialist3,
  5. Kaz Williams, patient author4,
  6. Helen Simpson, consultant in endocrinology and clinical advisor on the guideline5
  7. on behalf of the Guideline Development Group
    1. 1National Institute for Health and Care Excellence, London, UK
    2. 2The Longcroft Clinic, Surrey, UK
    3. 3Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
    4. 4Bristol, UK
    5. 5UCLH NHS Foundation Trust, London, UK
    1. Correspondence to H Simpson helen.simpson22{at}nhs.net

    What you need to know

    • Adrenal insufficiency is often unrecognised and can lead to adrenal crisis and death if not identified and treated

    • Offer an 8-9am serum cortisol test to people aged one year and older with suspected adrenal insufficiency

    • Treat adrenal crises with hydrocortisone and fluid rehydration, and transport the patient to hospital quickly

    • Discuss the following with patients who have confirmed adrenal insufficiency: sick day rules, how to administer emergency hydrocortisone, and the need for extra hydrocortisone cover when faced with stressors, including intercurrent illness

    Adrenal insufficiency is the inadequate production of the hormone cortisol from the adrenal glands. Global prevalence ranges from 0.4/100 000 (South Korea) to 15-22/100 000 (Nordic countries) for primary adrenal insufficiency, and 14-28/100 000 (Spain and UK) for secondary adrenal insufficiency.1 It is often unrecognised, which can lead to adrenal crisis and, if not identified and treated, death. From July 2018 to July 2020, NHS England National Reporting and Learning System identified 78 incidents related to adrenal insufficiency, including two deaths and six incidents of severe harm to patients across England.2

    Care is variable across the UK but there is a lack of understanding on who is at risk of adrenal insufficiency, how to test for it, and how to manage a life threatening adrenal crisis promptly. Here we summarise newly published guidelines from the National Institute for Health and Care Excellence (NICE).

    Recommendations

    NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the guideline committee’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

    GRADE Working Group grades of evidence

    • High certainty—we are very confident that the true effect lies close to that of the estimate of the effect.

    • Moderate certainty—we are moderately confident in the effect …

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