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Licensed Unlicensed Requires Authentication Published by De Gruyter June 29, 2019

Primary adrenal insufficiency in the United States: diagnostic error and patient satisfaction with treatment

Elizabeth A. Regan EMAIL logo , Anand Vaidya , Paul L. Margulies , Barry J. Make , Katherine E. Lowe and James D. Crapo
From the journal Diagnosis



The objective of the study was to assess the diagnostic process, access to care and treatment adequacy for primary adrenal insufficiency (PAI) patients from a US-based online registry.


The National Adrenal Diseases Foundation (NADF) patient registry from 2015 to 2016 was used for a cross-sectional assessment of PAI patients. Five hundred and forty-one adults met the study inclusion criteria (US residents, age >20, self-reported physician diagnosis of PAI and replacement dosing for cortisol). Issues in diagnosis, comorbid conditions, symptoms, with demographic and socioeconomic characteristics were determined. Disease management assessment included medication dose, patient satisfaction with function, and education. Factors associated with adrenal crisis were noted.


The cohort was predominantly female (83%), non-Hispanic White (97%), and well-educated (94% > high school education). A majority (57%) of patients reported difficulty with initial diagnosis, while 27% felt that their current steroid replacement was not adequate. Comorbid thyroid disease and other autoimmune conditions were common among PAI patients in the registry. More than three-quarters (78%) of patients used hydrocortisone for glucocorticoid replacement with a mean dose of 24.4 (standard deviation [SD]: 8.7) mg. Mean dose of hydrocortisone has declined over time following current treatment recommendations.


Timely, accurate diagnosis remains a problem for patients with primary adrenal insufficiency in an affluent, well-educated US cohort. Episodes of adrenal crisis are common and replacement steroid treatment is not always effective for patient function. Comprehensive information about outcomes of care for PAI in the US remains limited and the establishment of a research-specific registry to foster future research may be desirable. Patient registry data is a valuable source of information on diagnostic error and outcomes of care in rare diseases.

Corresponding author: Elizabeth A. Regan, MD, PhD, Department of Medicine, National Jewish Health, 1400 Jackson St, K706, Denver, CO 80206, USA; and Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA, Phone: +303-398-1531, Fax: +303-270-2249

  1. Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

  2. Research funding: None declared.

  3. Employment or leadership: None declared.

  4. Honorarium: None declared.

  5. Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.

  6. Disclosure: The authors report no conflicts of interest in this work.


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Received: 2019-03-25
Accepted: 2019-06-07
Published Online: 2019-06-29
Published in Print: 2019-11-26

©2019 Walter de Gruyter GmbH, Berlin/Boston

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