Adrenal

Who to refer:

Incidental adrenal mass

Refer all patients with an incidental adrenal mass found on routine imaging to endocrinology.

The endocrine team will triage the referral and arrange biochemical assessment, clinic review, surgical referral or radiological follow-up as appropriate.

Suspected adrenal insufficiency

For patients with suspected adrenal insufficiency, a 9 am cortisol is a useful initial investigation in primary care.

A 9 am cortisol greater than 275 nmol/L is usually reassuring.

If the 9 am cortisol is less than 275 nmol/L and adrenal insufficiency is suspected, please refer to endocrinology.

A cortisol below 275 nmol/L is not diagnostic of adrenal insufficiency. Morning cortisol has wide biological variation, and many patients with results below this threshold will have normal adrenal function. Lower results, particularly below 100–150 nmol/L, make adrenal insufficiency more likely.

Do not use serum cortisol as a screening test for adrenal insufficiency in pregnancy or in patients taking an oestrogen-containing combined oral contraceptive pill. Increased cortisol-binding globulin can make total serum cortisol difficult to interpret. Please seek endocrine advice instead.

Patients with significant hypotension, severe hyponatraemia, hypoglycaemia, vomiting, collapse or other features suggesting adrenal crisis should be discussed urgently with the endocrine registrar on call or referred for acute hospital assessment.

Hyponatraemia is covered in the separate RefHelp hyponatraemia guidance.

Established adrenal or pituitary disease

Patients with Addison’s disease, congenital adrenal hyperplasia, known adrenal insufficiency, or pituitary disease should be under endocrine follow-up.

Please refer to endocrinology if a patient with one of these conditions is not currently under specialist follow-up.

Suspected phaeochromocytoma or paraganglioma

Many phaeochromocytomas now present as incidental adrenal masses. These patients should be referred to endocrinology as adrenal incidentalomas. Patients with a suspected phaeochromocytoma or paraganglioma should be referred to endocrinology.

Clinical features that may suggest phaeochromocytoma include:

• Sustained or paroxysmal hypertension
• Episodic pallor
• Episodic sweating
• Palpitations or tachycardia
• Headache
• Tremor
• Anxiety or a feeling of impending doom

Facial flushing is not typical of phaeochromocytoma.

If 24-hour urine metanephrines are being checked in primary care, please ensure that the collection is sent in a container with acid preservative.

Suspected adrenal insufficiency and thyroid hormone replacement

Do not start levothyroxine in a patient with suspected adrenal insufficiency until adrenal insufficiency has been treated or excluded.

Starting thyroid hormone replacement in untreated adrenal insufficiency can precipitate adrenal crisis.

Who not to refer:

Suspected primary aldosteronism without an adrenal mass

Patients suspected of having primary aldosteronism, but who do not have an adrenal mass, should be referred via the local hypertension pathway rather than the adrenal clinic.

Patients who may have primary aldosteronism include:

• Patients with hypertension and spontaneous or unexplained hypokalaemia
• Patients with resistant hypertension
• Patients with hypertension and a family history of primary aldosteronism
• Patients with hypertension and stroke under the age of 40

Patients with both hypertension and an adrenal mass should be referred to endocrinology as an adrenal incidentaloma.

Incidental adrenal mass

No specific endocrine investigations are required in primary care before referral. Please refer to endocrinology and the endocrine team will arrange appropriate testing.

Suspected adrenal insufficiency

If clinically appropriate, check a 9 am cortisol before referral.

• Greater than 275 nmol/L: usually reassuring
• Less than 275 nmol/L: refer to endocrinology if adrenal insufficiency is suspected

Do not check serum cortisol as a screening test in pregnancy or in patients taking an oestrogen-containing combined oral contraceptive pill. Please seek endocrine advice instead.

If the patient is acutely unwell with features suggesting adrenal crisis, discuss urgently with the endocrine registrar on call or arrange acute hospital assessment.

Patients on long-term steroid therapy

Patients taking long-term oral, inhaled, topical, intra-articular or intramuscular glucocorticoids may be at risk of adrenal suppression.

Please see local guidance on management of long-term high-dose steroid therapy.

Patients with established adrenal insufficiency or significant risk of adrenal insufficiency should have appropriate sick day advice and a steroid emergency card.

Addison’s Disease Self-Help Group:
https://www.addisonsdisease.org.uk/