Presentations
- Cardiac arrythmia
- Electrolyte disturbance
- Fatigue
- Fractures
- Headache
- Hirsutism
- Hypertension:
- Hypotension
- Incidental adenoma
- Menstrual disturbance
- Metabolic syndrome
- Pallor
- Palpitations
- Sweating
- Weight gain/Obesity
- Weight loss
Conditions
- Adrenal cancer
- Adrenal insufficiency/failure:
- adrenoleukodystrophy
- autoimmune:
- Addison's disease
- immunotherapy related
- polyglandular autoimmune syndrome
- haemorrhage
- idiopathic
- infarction
- infection
- Adrenal metastasis
- Adrenal nodular disease:
- functional:
- Conns syndrome/ hyperaldosteronism
- Cushings syndrome/ hypercortisolism
- phaeochromocytoma/catecholamine-producing
- non-functional
- Congenital adrenal hyperplasia
- Macronodular adrenal hyperplasia
- Phaeochromocytoma
- Primary adrenocortical
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Conditions
- Inherited adrenal disorders:
- congenital adrenal hypoplasia
- MEN2A, MEN2B/3 VHL
- micronodular adrenal disease/Carney complex
- X-linked adrenal leukodystrophy
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Clinical science
- Anatomy, physiology, and histopathology of the normal and the abnormal adrenal gland (cortex and medulla), hypothalamic-pituitary-adrenal axis and sympathetic/parasympathetic ganglia
- Epidemiology and natural history of adrenal hormone excess disorders
- Epidemiology of genetic predisposition to adrenal disease
- Function and regulation of the adrenal gland
Diagnostic work up
- Aetiology, pathology, and clinical manifestations of adreno-cortical hormone deficiency, primary and secondary
- Aetiology, pathology, and clinical manifestations of adrenal hormone excess:
- hyperaldosteronism
- hypercortisolism
- phaeochromocytoma
- virilising tumours
- History, physical examination, and diagnostic work up of patient suspected of presenting with adrenal disease
- Limitations, indications, and interpretation of biochemical assays in the diagnostic work up of adrenal disorders:
- complex diagnostic work up and pitfalls in Cushing syndrome
- diagnostic work up and pitfalls in hyperaldosteronism
- different genetic disorders affecting the adrenal gland
- impact of medications on the assessment of hormone excess and deficiency
Medical management considerations
- Emergency and long-term management of hypoadrenalism due to primary and secondary adrenal insufficiency:
- prescribing and monitoring of glucocorticoid and/or mineralocorticoid
- screening for associated disorders
- Medical management of adrenal disorders of excess hormone production and monitoring of the underlying condition
- Monitoring of treatment efficacy
- Pharmacological principles of medications used in adrenal disorders:
- alpha and beta-receptor antagonists
- glucocorticoids
- mineralocorticoid receptor antagonists
- mineralocorticoids
- steroid biosynthesis inhibitors, such as:
Investigations
- Biochemical investigation of adrenal disease, including the hypothalamic-pituitary-adrenal axis:
- baseline testing
- dynamic testing
- Imaging:
- CT adrenal protocol
- MRI
- PET scan
- Interpretation of biochemical testing in the clinical context:
- dynamic endocrine testing
- specific understanding of indications (and contraindications):
- investigation for suspected Cushing syndrome, such as:
- dexamethasone suppression tests
- salivary testing
- urine testing
- short synacthen test
- Investigation for suspected Conn's syndrome:
- fludrocortisone suppression test
- seated saline suppression test
- Laboratory biochemistry:
- timing, patient preparation, and assay platforms suited for adrenal hormone testing
Procedures
- Indications for adrenal vein sampling
- Indications for adrenalectomy
- Indications for chemotherapy for malignant adrenal lesions
- Pre-, peri- and postoperative management of patients with adrenal disease, with particular emphasis on prevention of adrenal crisis and preoperative preparation and perioperative management of phaeochromocytoma
Evidence-based practice
- Remain abreast of evidence for best practice and apply this using clinical judgement and individual circumstances in partnership with patients
- Seek multidisciplinary care/review from centres of expertise wherever necessary
General management considerations
- Impact of adrenal disease and/or genetic diagnoses on the patient, their partner and, where applicable, their family/carers
- Incorporate environmentally sustainable practices in clinical care
- Longitudinal and multidisciplinary care needs of people with adrenal disease
- Mitigate clinical risk with sick day management plans when applicable, including use of medical alert bracelets or similar
- Options for improving equitable access to comprehensive care for individuals, such as:
- appropriate multicultural resources
- multidisciplinary involvement
- use of telehealth and other digital health tools
- Pre-, peri- and postoperative management of patients with adrenal disease
- Screening and genetic counselling of patients with inherited adrenal disease and referral of their family members if appropriate and with informed consent
Health needs of specific patient groups
- Preconception counselling and pregnancy management of women with congenital adrenal hyperplasia
- Multidisciplinary care of patients with adrenal cancer or malignant phaeochromocytoma/paraganglioma
