Table 4.

Current gaps in care of patients with adrenal insufficiency

Patient	Clinician	Societal support
Diagnosis   1. Understanding diagnosis, including type of adrenal insufficiency, so that patients can relay this information as needed for medical care and social support 2. For patients with PAI, special attention is needed for understanding added implications of mineralocorticoid deficits Chronic management of AI 3. Consistency with taking GC regimen 4. Understanding symptoms of under- and over-replacement of GC in an effort to effectively communicate dosing issues to the healthcare team 5. For patients with PAI, orthostatic blood pressure education may be beneficial to assess adequacy of mineralocorticoid replacement Prevention and treatment of adrenal crisis 6. Taking stress dose glucocorticoids when indicated (to avoid adrenal crisis) and avoiding stress dose GC when not indicated (to avoid complications of GC) 7. Consistency with wearing medical alert gear 8. Availability of home injectable GC and comfort with administration if needed	Diagnosis   1. Since diagnosis of AI is frequently delayed, clinicians must be educated regarding the signs and symptoms of AI and the approach to diagnostic confirmation. 2. Testing for AI should occur immediately with expedited access to endocrine expertise if needed for diagnosis and treatment. Consultation can take the form of telemedicine or phone consultation as appropriate 3. The endocrine community has a responsibility to educate surrounding primary care and emergency room clinicians about diagnosing AI. 4. Clinicians must allocate sufficient time to explaining AI to patient and family Chronic management of AI 5. Every patient with AI would benefit from an adrenal action plan may serve as a written record of AI type, standard replacement, and replacement at times of illness 6. Appropriate GC replacement to avoid under- and over-replacement 7. For patients with PAI, appropriate mineralocorticoid replacement to maintain clinical euvolemia and electrolytes Prevention and treatment of adrenal crisis 8. Educate patients on importance of wearing medical alert gear and maintaining copy of adrenal action plan for cases of emergency 9. Review indications for stress dose GC at every visit and maintain an active prescription for injectable GC 10. Provide education for local emergency room staff regarding identification and prompt management of adrenal crisis. Specifically, all patients with AI should be given IV GC; patients with PAI (lacking mineralocorticoid activity) may additionally require aggressive volume expansion with IV fluid	Diagnosis   1. Assure optimal insurance reimbursement for adrenal insufficiency diagnosis and care 2. Facilitate access to adrenal endocrinologists Chronic management of AI 3. Support person would benefit from education about AI to increase understanding of the condition 4. Multiple types of support networks (online and in-person) to serve varied roles, including opportunities for patient/family education, forums for group support, and access to open discussion with adrenal experts 5. Insurance coverage of crucial medical treatments including injectable GC Prevention and treatment of adrenal crisis 6. Support person should be taught to recognize symptoms of adrenal crisis 7. Support person should have access to adrenal action plan and receive education of administration of injectable GC

Abbreviations: AI, adrenal insufficiency; IV, intravenous; PAI, primary adrenal insufficiency; GC, glucocorticoid.