The Changing Epidemiology of Adrenal Insufficiency: Iatrogenic Factors Predominate

Abstract

Context Adrenal insufficiency-related morbidity persists despite efforts to minimise its impact. Reasons for this are unknown and warrant examination. Objective To investigate trends in adrenal insufficiency hospitalisations and glucocorticoid replacement therapy use. Methods Data on hospitalisations for a principal diagnosis of adrenal insufficiency and prescriptions for short-acting glucocorticoids between 2000 to 2019 were extracted from national repositories. Age standardised admission and prescription rates were calculated using census data. Rates were compared over time overall and according to age, sex, and disease subtype. Results Adrenal insufficiency admissions increased by 62.0%, from 36.78/million to 59.59/million (trend p < 0.0001). Adrenal crisis admissions also increased, by 90.1% (from 10.73/million to 20.40/million, trend, p < 0·00001). These increases were more pronounced in the second decade. Prescriptions for short-acting glucocorticoids also increased (by 67.2%, from 2198.36/million in 2000/1 to 3676.00/million). Females had higher average admission rates and a greater increase in admission rates than males. Increased adrenal insufficiency admissions were found in all age groups among females but only in men aged 70 + yrs. Secondary adrenal insufficiency admission rates increased by 91.7%, while admission rates for primary adrenal insufficiency remained unchanged. Conclusion The prevalence of adrenal insufficiency and hospitalisations for this disorder (including adrenal crises) have increased since 2000, with a greater increase occurring after 2010. Admission rates for secondary adrenal insufficiency increased but primary adrenal insufficiency admissions remained stable. Possible causes include immunotherapies for malignancy, increased cranial imaging detecting pituitary tumours and their subsequent treatment, and increased use of low dose short acting glucocorticoid replacement therapy.