Addison Disease

Updated: Jan 13, 2022
  • Author: George T Griffing, MD; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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Practice Essentials

Addison disease (or Addison's disease) is adrenocortical insufficiency due to the destruction or dysfunction of the entire adrenal cortex. It affects glucocorticoid and mineralocorticoid function. The onset of disease usually occurs when 90% or more of both adrenal cortices are dysfunctional or destroyed. [1]

Thomas Addison first described the clinical presentation of primary adrenocortical insufficiency in 1855 in his classic paper, On the Constitutional and Local Effects of Disease of the Supra-Renal Capsules. [2]

Signs and symptoms of Addison disease

Signs and symptoms of chronic Addison disease can include the following:

  • Hyperpigmentation
  • Vitiligo
  • Weakness
  • Fatigue
  • Poor appetite
  • Weight loss
  • Nausea
  • Vomiting
  • Occasional diarrhea
  • Dizziness with orthostasis
  • Myalgias and flaccid muscle paralysis
  • Joint pains
  • Heightened sense of smell, taste, and hearing
  • Salt craving
  • Impotence and decreased libido may occur in male patients
  • History of amenorrhea in female patients

Signs and symptoms of acute Addison disease can include the following:

  • Patients in acute adrenal crisis most often have prominent nausea, vomiting, and vascular collapse; they may be in shock and appear cyanotic and confused
  • Abdominal symptoms may take on features of an acute abdomen
  • Patients may have hyperpyrexia, with temperatures reaching 105° F or higher, and may be comatose
  • In acute adrenal hemorrhage, the patient, usually in an acute care setting, deteriorates with sudden collapse, abdominal or flank pain, and nausea with or without hyperpyrexia

Workup in Addison disease

The diagnosis of adrenocortical insufficiency rests on the assessment of the functional capacity of the adrenal cortex to synthesize cortisol. This is accomplished primarily by use of the rapid adrenocorticotrophic hormone (ACTH) stimulation test (Cortrosyn, cosyntropin, or Synacthen). [3]

In acute adrenal crisis, where treatment should not be delayed in order to do the tests, a blood sample for a random plasma cortisol level should be drawn prior to starting hydrocortisone replacement.

Other tests performed in the diagnosis of Addison disease include the following:

  • Comprehensive metabolic panel
  • Complete blood cell (CBC) count
  • Thyroid-stimulating hormone (TSH) levels
  • Autoantibody testing: Thyroid and/or adrenal autoantibodies may be present
  • Prolactin testing: Modest hyperprolactinemia has been reported in cases of Addison disease and also in secondary adrenocortical insufficiency

Imaging studies include the following:

  • Chest radiograph:
  • Computed tomography (CT) scan: An abdominal CT scan may be normal but may show bilateral enlargement of the adrenal glands in patients with Addison disease because of tuberculosis (TB), fungal infections, adrenal hemorrhage, or infiltrating diseases involving the adrenal glands

Management of Addison disease

Corticosteroid drugs are used for replacement therapy in Addison disease and secondary adrenocortical insufficiency. [4, 5] Hydrocortisone sodium succinate or phosphate is the drug of choice for daily maintenance in these conditions and in the treatment of acute adrenal crisis.

In patients in acute adrenal crisis, intravenous (IV) access should be established urgently, and an infusion of isotonic sodium chloride solution should be begun to restore volume deficit and correct hypotension. Some patients may require glucose supplementation. The precipitating cause should be sought and corrected where possible.




United States

The prevalence of Addison disease is 40-60 cases per 1 million population.


The occurrence of Addison disease is rare. The reported prevalence in countries where data are available is 39 cases per 1 million population in Great Britain and 60 cases per 1 million population in Denmark. A study by Olafsson and Sigurjonsdottir found the prevalence of primary adrenal insufficiency in Iceland to be 22.1 per 100,000 population. [6]  A study by Hong et al found the prevalence of primary adrenal insufficiency in Korea to be 4.17 per 1 million population. [7]


Morbidity and mortality associated with Addison disease usually are due to failure or delay in making the diagnosis or a failure to institute adequate glucocorticoid and mineralocorticoid replacement. [8]

If not treated promptly, acute addisonian crisis may result in death. This may be provoked either de novo, such as by adrenal hemorrhage, or in the setting of an acute event superimposed on chronic or inadequately treated adrenocortical insufficiency.

With slow-onset chronic Addison disease, significant low-level, nonspecific, but debilitating, symptomatology may occur.

Even after diagnosis and treatment, the risk of death is more than 2-fold higher in patients with Addison disease. Cardiovascular, malignant, and infectious diseases are responsible for the higher mortality rate. [9]

A study by Skov et al indicated that females with autoimmune Addison disease are at increased risk of ischemic heart disease, with an adjusted hazard ratio (aHR) of 2.15 compared with controls. The aHR in males, however, was just 1.16. In women, but not in men, higher glucocorticoid and mineralocorticoid replacement doses were independently correlated cardiovascular disease risk. The investigators found that overall in patients with autoimmune Addison disease, there were 10.7 events of first cardiovascular disease/1000 person-years, compared with 7.0 events/1000 person-years in controls. [10]

White and Arlt examined the prevalence of and risk factors for adrenal crisis in patients with Addison disease, utilizing a survey of Addison patients in the United Kingdom, Canada, Australia, and New Zealand. The authors' results indicated that approximately 8% of patients diagnosed with Addison disease require annual hospital treatment for adrenal crisis. In addition, the investigators concluded that exposure to gastric infection is the most important risk factor for adrenal crisis in the presence of Addison disease; diabetes and/or asthma [11] concomitant with Addison disease also increase the risk, according to White and Arlt. [12]

A study by Chantzichristos et al indicated that in patients with type 1 or 2 diabetes, those who also have Addison disease have a higher mortality rate than do those with diabetes alone. Over a median follow-up period of 5.9 years, the mortality rate for diabetes patients with Addison disease was 28%, compared with 10% for those without Addison disease. The increase in the estimated relative overall mortality risk was 3.89 for the Addison disease patients compared with the other group. Although cardiovascular deaths accounted for the highest mortality rate in both groups, the death rate from diabetes complications, infectious diseases, and unknown causes was greater in the patients with Addison disease than in those with diabetes alone. [13]

A study by Vogt et al of women with autoimmune Addison disease found that 10.2% of them developed primary ovarian insufficiency (POI; ie, menopause before age 40 years), with a third of POI cases occurring before age 30 years. In more than 50% of the women with POI, the insufficiency developed prior to or coincided with the diagnosis of autoimmune Addison disease. Autoantibodies against the side-chain cleavage enzyme were determined to be useful markers for autoimmune POI, having a negative predictive value of 96%. [14]


Addison disease is not associated with a racial predilection.


Idiopathic autoimmune Addison disease tends to be more common in females and children.


The most common age at presentation in adults is 30-50 years, but the disease could present earlier in patients with any of the polyglandular autoimmune syndromes or congenital adrenal hyperplasia (CAH) or in those in whom the onset is due to a disorder of long-chain fatty acid metabolism.