Key messages

• In gradually developing primary hypoadrenalism, increasing weakness, fatigue, lassitude, anorexia, myalgia, and weight loss are the first symptoms.

• In acute adrenal failure symptoms are generally non-specific and may include vomiting, diarrhea, abdominal pain, weakness, myalgias, joint pains, lethargy, confusion, delirium, or even coma.

• A basal cortisol concentration below 275 mmol/l (<10 g/dl) strongly suggests hypoadrenalism, and a level of 550 nmol/l (20 g/dl) or above argues strongly against it. A short ACTH (tetracosactrin) stimulation test should be performed in virtually all patients in whom the diagnosis is considered.

• Dexamethasone (4 mg) or hydrocortisone (100 mg) are the glucocorticoid preparations of choice in the emergency situation and should be immediately injected intravenously.

• Correction of hypovolemia requires a large volume (usually at least 3 liters) of 0.9 per cent saline which also improves hyponatremia.

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