OBJECTIVES: To obtain information regarding the presence of cardiometabolic risk factors among adrenal insufficiency (AI) patients in Italy. To understand treatment patterns and goals and to gain consensus regarding how effectively existing therapies meet these goals. METHODS: A two-stage Delphi process was conducted with four Italian key opinion leaders (KOLs). Each KOL completed an electronic survey eliciting information regarding AI management and the prevalence and importance of risk factors. To reach a consensus on the key issues, the results were discussed at a face-to-face meeting. RESULTS: The KOLs agreed that avoiding adrenal crisis is the main treatment goal, and that quality of life and avoiding fatigue are most important to patients. Patients typically receive 20–30 mg cortisone acetate or hydrocortisone daily in 2-3 administrations. A consensus was reached that cardiometabolic risk factors are not hallmarks of AI, but are related to its glucocorticoid replacement treatment (GC) either due to overtreatment or non-physiological replacement of serum cortisol. In agreement with the available evidence in the literature they suggested that the increase risk may be associated with the non-physiological cortisol peaks and troughs that are characteristic of the existing GC replacement therapies. They established that 50% of AI patients are over treated, often to minimise the risk of adrenal crisis and all patients currently face non-physiological cortisol replacement, given the available treatments. GC replacement–related risks included (prevalence in AI in parentheses): hypertension (10–30%), abdominal obesity (15–35%), dyslipidaemia (33%) and metabolic syndrome (30–35%).  CONCLUSIONS: The prevalence of cardiometabolic risk factors is associated with the treatment of AI, not AI itself. Over-treatment and non-physiological cortisol replacement may explain cardiometabolic risks. A physiological alternative to existing treatments would be welcomed in Italy.