National Survey Reveals Gaps in Brazilian Endocrinologists’ Education Practices on Adrenal Insufficiency

Daniela Barros, post graduate student of the Surgical Clinic Program at Ribeirão Preto Medical School, University of São Paulo (FMRP-USP), Ribeirão Preto, SP, Brasil.

Adrenal crisis is a life-threatening emergency that remains under-recognized and often inadequately managed in clinical practice. Despite standardized glucocorticoid replacement therapy, epidemiological studies estimate an incidence of five to ten adrenal crises per 100 patient-years, with significant associated morbidity and mortality. Effective prevention depends largely on patient education and physician guidance regarding stress-related dose adjustments and emergency self-administration of glucocorticoids.

In this context, a national survey of 280 Brazilian endocrinologists, conducted by researchers from the Universidade Federal do Rio de Janeiro and Universidade Federal Fluminense, provides the first comprehensive overview of current practices in Brazil.

The results, published in the article A national survey of Brazilian endocrinologists’ practices in educating patients with adrenal insufficiency on stress-induced glucocorticoid adjustments (Archives of Endocrinology and Metabolism, vol. 69, no. 4, 2025), reveal only moderate adherence to international guidelines. On average, physicians answered correctly 63.3% of clinical vignettes assessing stress-induced glucocorticoid adjustments. More concerning, 41.1% of respondents failed to endorse patient self-administration of intramuscular hydrocortisone during adrenal crisis, an evidence-based cornerstone of emergency management.

The study also highlighted variability related to age, clinical experience, and practice setting: physicians working in both outpatient and hospital environments demonstrated superior knowledge, while older clinicians tended toward more conservative, sometimes harmful, dosing recommendations. Moreover, those with over five years since graduation performed better in scenarios such as vaginal delivery and gastroenteritis.

These findings underscore a critical gap in physician practices and patient education in Brazil, raising urgent questions about training, continuing education, and access to emergency medications.

The investigators developed an online questionnaire disseminated nationwide via professional networks (including WhatsApp groups). The survey combined demographic questions with ten clinical vignettes addressing diverse scenarios such as delivery, infections, gastrointestinal illness, and surgical procedures. Recommendations were benchmarked against Endocrine Society guidelines (BORNSTEIN, S.T., et al., 2016). Responses were classified as correct, incorrect but harmless, or incorrect and potentially harmful. Statistical comparisons were made by physician demographics, practice settings, and years since graduation.

Physicians from 24 of 27 Brazilian states participated (mean age 43.9 years, mean time since graduation 19.4 years). The mean overall score was 63.3%. High adherence was noted for cesarean section management (87.9% correct), while concerning knowledge gaps emerged in routine contexts such as minor infections or procedures.

Notably, 41.1% of endocrinologists discouraged or failed to recommend patient self-injection of hydrocortisone in adrenal crisis, a position contrary to established recommendations.

The moderate performance of Brazilian endocrinologists aligns with findings from Germany, where physicians answered correctly in 72.9% of adrenal insufficiency-related questions (KAMPMEYER, D. et al., 2016). Similar patient-related data underscore the challenge: nearly half of patients cannot self-manage corticosteroid therapy during stress (HARSCH, I.A., et al., 2010), and international studies report that fewer than 15% of patients self-inject glucocorticoids during adrenal crises (BURGER-STRITT, S., et al., 2018; HAHNER, S., et al., 2015). These numbers illustrate the persistent gap between guideline recommendations and real-world practice, both at the physician and patient levels.

The Brazilian survey further highlights systemic barriers that may amplify this gap. Injectable hydrocortisone is primarily available in hospitals, limiting access for patients outside acute care settings. This scarcity may help explain why some physicians, even when aware of international standards, continue to recommend oral prednisone increases as substitutes during crises.

While practical, such strategies may delay effective management and expose patients to unnecessary risks. Initiatives such as the emergency kit provided by the Associação Brasileira Addisoniana represent important steps toward improving access and patient autonomy, but reluctance among physicians to encourage or train patients in self-administration perpetuates vulnerability.

Another critical dimension is the underestimation of relatively mild stressors. As highlighted by WHITE, K., et al. (2010) and HAHNER, S., et al., (2010), adrenal crises frequently originate from inadequate glucocorticoid adjustments in scenarios such as flu-like illnesses or gastrointestinal infections, which clinicians may perceive as benign. The Brazilian data mirror this concern: questions addressing these scenarios yielded some of the lowest adherence rates, underscoring the potential for preventable crises triggered by insufficient dosing during everyday stressors.

Educational aspects also emerge prominently. While older physicians tended to make more conservative recommendations, sometimes resulting in potentially harmful underdosing, younger endocrinologists demonstrated lower performance in certain scenarios, suggesting possible curricular gaps in undergraduate and postgraduate medical training. These results echo concerns that adrenal insufficiency and stress-related dosing may not receive adequate emphasis in current teaching programs.

From a broader health systems perspective, the findings carry implications for patient safety and resource utilization. International evidence suggests that patients trained in self-injection are more likely to manage adrenal crises outside hospital settings, reducing the burden on emergency services and associated healthcare costs. By contrast, delayed or inadequate treatment increases the likelihood of hospitalization, intensive care admission, and mortality.

In summary, the survey not only documents moderate adherence to guideline-based practices among Brazilian endocrinologists but also reveals structural, educational, and cultural challenges that compromise the optimal management of adrenal insufficiency.

Addressing these issues requires a multipronged approach: ensuring availability of injectable hydrocortisone beyond hospital settings, expanding patient access to emergency kits, strengthening physician training at all levels, and reinforcing the role of patient education as a cornerstone of crisis prevention. Such measures could significantly reduce the incidence of adrenal crises, improve quality of life, and ultimately lower the morbidity, mortality, and healthcare costs associated with this condition.

To read the article, access

NETO, L.V., et al. A national survey of Brazilian endocrinologists’ practices in educating patients with adrenal insufficiency on stress-induced glucocorticoid adjustments. Arch Endocrinol Metab. [online]. 2025, vol. 69, no. 14, e250098. [viewed 23 October 2025].  https://doi.org/10.20945/2359-4292-2025-0098. Available from: https://www.scielo.br/j/aem/a/tGmwfXLxbv7PzBDJpS3B5XD/

References

BORNSTEIN, S.T., et al. Diagnosis and treatment of primary adrenal insufficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. [online]. 2016, vol.101, pp. 364-389. [viewed 23 October 2025]. http://dx.doi.org/10.1210/jc.2015-1710. Available from: https://pubmed.ncbi.nlm.nih.gov/26760044/

BURGER-STRITT, S., et al. Management of adrenal emergencies in educated patients with adrenal insufficiency-A prospective study. Clin Endocrinol (Oxf). [online]. 2018, vol. 89, no. 1, pp. 22-29. [viewed 23 October 2025]. https://onlinelibrary.wiley.com/doi/10.1111/cen.13608. Available from: https://pubmed.ncbi.nlm.nih.gov/29617051/

HARSCH, I.A., et al. Cortisone replacement therapy in endocrine disorders – quality of self-care. J Eval Clin Pract. [online]. 2010, vol. 16, no. 3, pp.492-498. [viewed 23 October 2025]. https://doi.org/10.1111/j.1365-2753.2009.01149.x. Available from: https://pubmed.ncbi.nlm.nih.gov/20210825/

HAHNER, S., et al. High incidence of adrenal crisis in educated patients with chronic adrenal insufficiency: a prospective study. J Clin Endocrinol Metab. [online]. 2015, vol.100, no. 2, pp. 407-416. [viewed 23 October 2025]. https://doi.org/10.1210/jc.2014-3191. Available from: https://pubmed.ncbi.nlm.nih.gov/25419882/

HAHNER, S., et al. Epidemiology of adrenal crisis in chronic adrenal insufficiency: the need for new prevention strategies. Eur J Endocrinol. [online]. 2010, vol. 162, no. 3, pp. 597-602. [viewed 23 October 2025] https://doi.org/10.1530/EJE-09-0884. Available from: https://pubmed.ncbi.nlm.nih.gov/19955259/

KAMPMEYER, D., et al. A strong need for improving the education of physicians on glucocorticoid replacement treatment in adrenal insufficiency: An interdisciplinary and multicentre evaluation. Eur J Intern Med. [online]. 2016, vol. 33, pp.e13-15. [viewed 23 October 2025]. https://doi.org/10.1016/j.ejim.2016.04.006. Available from: https://pubmed.ncbi.nlm.nih.gov/27108240/

WHITE, K., et al. Adrenal crisis in treated Addison’s disease: a predictable but under-managed event. Eur J Endocrinol. [online]. 2010, vol. 162, no. 1, pp. 115-120. [viewed 23 October 2025]. https://doi.org/10.1530/EJE-09-0559. Available from: https://pubmed.ncbi.nlm.nih.gov/19776201/

External links

Archives of Endocrinology and Metabolism – AEM