Current RMA Instruments
| Reasonable Hypothesis SOP | 58 of 2026 |
| Balance of Probabilities SOP | 59 of 2026 |
Changes from previous Instruments
ICD Coding
- ICD-10-AM Codes: E27.1, E27.2, E27.3, E27.4, E89.6, A18.7, A39.1
Brief description
Adrenal insufficiency is an endocrine disease characterised by deficient production of adrenal cortical hormones, including cortisol, mineralocorticoids and adrenal androgens. The hormone deficiency must be biochemically demonstrated, sufficient to produce clinical symptoms and signs, and necessitate glucocorticoid, mineralocorticoid or adrenal androgen replacement therapy.
Adrenal insufficiency may be primary or secondary and may present as an acute or chronic condition. Acute adrenal insufficiency may present as an adrenal crisis.
Primary adrenal insufficiency is also known as Addison disease. Drug-induced adrenal insufficiency is included within the SOP.
Confirming the diagnosis
Adrenal insufficiency requires assessment and diagnosis to be made by an Endocrinologist or General Physician. Confirmation of adrenal insufficiency requires biochemical evidence of deficient adrenal cortical hormone production in the appropriate clinical context. Symptoms and signs are often non-specific and may include nausea, vomiting, abdominal cramps, diarrhoea, fatigue, myalgias, arthralgias, weakness, fever, dizziness, weight loss, amenorrhoea, decreased libido and depression.
Assessment generally includes measurement of serum cortisol and, where indicated, ACTH and dynamic testing such as an ACTH stimulation test. Additional investigations such as imaging may be required to determine whether the adrenal insufficiency is primary or secondary and to establish the underlying cause.
For the purposes of the SoP, biochemical abnormalities alone are insufficient. The hormone deficiency must be sufficient to produce clinical symptoms and signs and necessitate glucocorticoid, mineralocorticoid or adrenal androgen replacement therapy.
Additional diagnoses covered by SOP
- Acute hypoadrenalism
- Addison’s disease
- Addisonian crisis
- Adrenal crisis/Adrenocortical crisis
- Chronic hypoadrenalism
- Drug-induced hypoadrenalism
- Primary adrenocortical insufficiency
- Secondary adrenocortical insufficiency
Conditions excluded from SOP
- Adrenal medullary insufficiency #
- Cushing disease/syndrome *
- Hereditary forms of adrenal insufficiency #
- Hypopituitarism *
* another SOP applies
# non-SOP condition
Clinical onset
Clinical onset refers to the earliest point at which adrenal insufficiency meeting the SOP definition can reasonably be identified. Symptoms alone do not establish clinical onset because they are generally non- specific. In most cases, clinical onset will correspond to the point at which compatible clinical symptoms and signs are associated with biochemically demonstrated deficient adrenal cortical hormone production of sufficient severity to necessitate replacement therapy. An earlier isolated abnormal cortisol result, without the other elements required by the SOP definition, would not by itself establish clinical onset.
Where adrenal insufficiency first presents acutely as an adrenal crisis, the onset of that presentation may represent the clinical onset of the disease if the diagnostic requirements are subsequently established.
Clinical worsening
Clinical worsening may occur as deterioration of established adrenal insufficiency or as an acute adrenal crisis. Relevant features may include increasing symptoms or signs of hormone deficiency, deterioration in biochemical control, increased replacement requirements, or development of an adrenal crisis.
When assessing clinical worsening, consideration should be given to whether the deterioration represents a sustained or clinically significant worsening of the adrenal insufficiency rather than a transient fluctuation in symptoms or laboratory results. Acute adrenal crisis may represent a manifestation of worsening and requires urgent treatment. However, general worsening of chronic adrenal insufficiency may also occur. Due to the complexity of this condition, assessment by an endocrinologist or general physician is recommended when assessing whether there has been genuine clinical worsening or whether changes reflect treatment, intercurrent illness or the expected course of the underlying disorder.