Adrenal Insufficiency in ASEAN: Barriers and Variations in Diagnosis and Management

Background Adrenal insufficiency (AI) is a potentially life-threatening condition that requires timely diagnosis and lifelong glucocorticoid replacement. While extensively studied in Western populations, limited data exist on the management of AI across countries within the Association of Southeast Asian Nations (ASEAN). Objective To assess current clinical practices, diagnostic strategies, and barriers to care in the management of AI in ASEAN. Methods We conducted a multicentre, cross-sectional survey of 131 physicians from eight countries across ASEAN between October 2024 and January 2025. Respondents included endocrinologists and non-endocrinologists from public and private healthcare sectors. Data was collected using an anonymized online questionnaire covering diagnosis, management and perceived barriers within the care of individuals with AI. Results Glucocorticoid-induced AI due to the use of traditional or herbal steroids was identified as the most frequently reported aetiology. Diagnostic practices varied widely; morning cortisol and stimulated test cut-offs ranged from < 100 to < 550 nmol/L and ≥ 200 to ≥ 550 nmol/L, respectively. Synacthen shortages and inconsistent assay access were major barriers. Over half of respondents (51.1%) used fixed glucocorticoid doses, and tapering practices were highly variable. Only 21.4% provided patients with emergency cards or bracelets. Patient adherence to sick day rules and tapering regimens was suboptimal. Key barriers included limited education tools, low health literacy, and restricted access to low-dose steroid formulations. Conclusion This first regional survey reveals significant heterogeneity in AI diagnosis and management across ASEAN. Harmonized protocols, assay-specific diagnostic thresholds, and regionally adapted patient education strategies are needed to improve care and reduce preventable morbidity.