Key questions to ask

• Has this person had prolonged steroids in the last 6 months?
• Does this patient have postural hypotension?
• Are they losing weight unintentionally?
• Do they have low/borderline blood sodium?
• Do they have salt, soy sauce or liquorice cravings, or increased thirst and urination?
• Do they have appropriate pigmentation, or has there been a change in skin colour? (primary adrenal insufficiency only)
• Is there a history of endocrine or autoimmune conditions, such as thyroid disorders,
  Type 1 diabetes, B12 deficiency or coeliac disease in the extended family

Screening

• Where the patient is stable, the GP should assess for clinical signs, especially:
  Blood pressure sitting and standing. A 20mmHg drop on standing indicates clear postural hypotension.
• Proximal myopathy or global muscle weakness (difficulty climbing stairs, getting up from a sitting/squatting position, or carrying weights, such as grocery shopping).
• Patchy hyperpigmentation or, in Caucasians, unusual pigmentation in the palmar/wrist creases (not present in 20% of cases, depending on the patient’s natural level of melanocytes). Hyperpigmentation is typically most obvious in areas of increased friction, such as the oral mucosa, knuckles, elbows or waistline

NOTE: If adrenal crisis is suspected, NEVER delay emergency treatment to perform investigations.

Key GP roles

• Understand the recommendations by the NICE Guidelines for the Identification and Management of Adrenal Insufficiency. See Guide for GPs and ACPs for detail.
• Sick Day Rules: understand Sick Day dosing, and when your patient should follow this guidance
• Ensure the patient's Summary Care Record is up-to-date: Many of our members report issues where their care has been 'hit and miss'.  Help ensure that other healthcare professionals are aware of their steroid-dependent status by ensuring that their SCR is accurate.
• Use digital alerts on the GP practice IT system to support remote monitoring for prompt prescriptions and priority appointments.
• Prescription Frequency: Ensure that your patients are given 3-monthly prescriptions of their essential steroid medications, allowing them to build a sufficient reserve for following Sick Day Rules. This is supported by the Society for Endocrinology (SfE) and the NICE guidelines (2024), Section 1.4.1 which state;

Offer additional supplies of oral glucocorticoids to cover increased dosing during periods of physiological stress (sick-day dosing).

Read more about the signifiance of 3-monthly prescriptions and how GPs can support their patients in calmer and effective self-management.

• Support your patient to stock their emergency injection kits: Prescription medication, needles and syringes all have an expiry date, or may be used, and will need replacing.  Needles and syringes are not currently on drug tariff, but we kindly request that you facilitate your patient re-stocking their life saving kits so they can be confident that they are prepared in the event of an adrenal crisis.  

Read: Why it is essential to provide an emergency injection kit

• Provide an NHS Steroid Emergency card (SEC) to highlight the time-critical, steroid-dependent nature of your patient's medication regimen.

• Surgical Guidelines: Remind patients of the need to ensure appropriate steroid cover during surgical procedures, including dental procedures

Surgical Guidelines

Dental Guidelines

• Feel confident to advise your patient with day-to-day considerations, such as diet, exercise, irregular work patterns, pregnancy and travel.

Explore our Lifestyle and Wellbeing sections

• Provide timely seasonal vaccinations (including COVID vaccination) to eligible patients.

Online training modules

Educate yourself on adrenal insufficiency of all types and adrenal crisis management
The ADSHG has worked alongside both RCGP and BMJ e-Learning, to author two e-learning modules for GPs and healthcare professionals wanting to refresh their knowledge around Addison's disease, adrenal insufficiency and managing adrenal crisis.

Resources to keep you up-to-date