Adrenal Insufficiency: Continuing Education Needed for Primary Care Physicians

Case study: A 42-year-old man with Addison’s disease and Hashimoto disease-related hypothyroidism presents for a routine physical. Management consists of hydrocortisone 12.5 mg AM and 5 mg PM, fludrocortisone 0.05 mg daily and levothyroxine 137 mcg daily. He has no complaints and says he feels well. Physical examination is unremarkable and lab test results show normal electrolytes and TSH, an ACTH level of 304 pg/mL (normal 8-42 pg/mL) and plasma renin activity of 2.3 μg/L/h (normal 0.8-5.8 μg/L/h). How should this man be treated?

1. Discontinue hydrocortisone and give prednisone 5 mg AM and 2.5 mg PM
2. Increase fludrocortisone to 0.10 mg daily
3. Increase hydrocortisone to 20 mg AM and 10 mg PM
4. Leave his corticosteroid doses unchanged

If you answered D, you selected the best response. The patient has obvious adrenal insufficiency (AI) but is well-controlled on his current regimen and feels well.

A difficult diagnosis to make

An educational quality improvement project involving 51 primary care physicians (PCPs) revealed that only 35% of respondents answered this question correctly, suggesting the need for further education.

According to Vinni Makin, MD, of Cleveland Clinic’s Endocrinology & Metabolism Institute, adrenal insufficiency is a challenging diagnosis to make and manage. Combined with the clinical challenge, patients may subscribe to the idea of “adrenal fatigue,” and insist that PCPs test and treat them, leading to the potential for unnecessary testing and inappropriate and potential harmful treatment with steroids.

“Adrenal fatigue is not a true medical condition,” Dr. Makin says, “and there are no data to support the theory that physical or emotional stress over a long period of time adversely impacts the function of the adrenal glands and causes a group of symptoms such as fatigue, sleeping issues, salt and sugar cravings and weight gain.”

Adrenal insufficiency, on the other hand, is a real — albeit rare — disease characterized by fatigue, nausea/vomiting, loss of appetite, large amounts of weight loss, low blood pressure, confusion and, in some cases, skin pigmentation. While it can be diagnosed via cosyntropin stimulation and insulin tolerance tests, these tests are expensive and the results are influenced by previous steriod use and certain other factors.

“Clinical judgment remains very important and unnecessary testing and referrals to endocrinologists are common. We wanted to assess how comfortable PCPs feel in making the diagnosis of adrenal insufficiency, distinguishing it from ‘adrenal fatigue,’ their need for education and their preferred learning format,” says Dr. Makin.

Dr. Makin conducted the 12-item questionnaire in person, in paper format over a six-month period at various family health centers. The results were recently published in the Journal of Primary Care & Community Health. Her colleagues Amy Nowacki, PhD, and Colleen Colbert, PhD, served as co-authors.

Average knowledge level

Of the 51 PCPs who agreed to participate in the survey, 59% were men and one-third had completed their residencies more than 20 years previously. Sixty-three percent (n = 32) of the PCPs were working with a trainee. The respondents self-rated their knowledge as follows:

• Below average: 22% (n = 11)
• Average: 76% (n = 39)
• Above average: 2% (n = 1)
• Expert: 0%

Self-assessments did not change whether a PCP was working with a trainee or not (P = 0.56).

Forty-nine clinicians answered four case-based clinical scenarios in which they were asked to select the best answer from a list of four options. Only two physicians (4%) scored 4 — the highest possible score — whereas 15 each scored 2 or 3, 16 (33%) scored 2 and 1 (2%) scored 0.

Changing educational demands

The majority of the physicians (88%) said they were interested in a new learning resource about adrenal insufficiency. When asked to rank their preferences for educational format, the respondents said they preferred an UpToDate article, followed by a traditional lecture and then a case-based format. An online module was ranked as the least desirable format.

“We were surprised that many of the physicians preferred the didactic lecture format over the case-based learning format that is more popular in the academic world today, but we surmised the reason being they completed training when the didactic teaching format was the norm,” Dr. Makin notes.

Dr. Makin has since conducted a Grand Rounds presentation for the Internal Medicine Department at Cleveland Clinic Fairview Hospital on adrenal insufficiency as a follow up to the survey; the PowerPoint slides she created for this lecture can be accessed here. She also recommends that PCPs and other providers print out an adrenal fatigue handout, created by the Hormone Health Network and the Endocrine Society, to give to patients who present with symptoms and want to be investigated for adrenal fatigue.

“It is critical that PCPs are up to date on adrenal insufficiency diagnosis and management, so they can educate physicians in training, advocate for patient safety and be role models for appropriate use of health care resources. Our survey shows that more education is clearly needed and desired by PCPs,” Dr. Makin concludes.